THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


EXAMINATION   OF  URINE. 


BY  THE  SAME  AUTHOR. 

THE  CELL  DOCTRINE  :  Its  History  and  Present  State,  to- 
gether with  a  copious  Bibliography  of  the  Subject.     With  a 
colored  plate  and  other  illustrations. 
Second  revised  edition.     Cloth,  price  $2.00. 

AN  INTRODUCTION  TO  THE  STUDY  OF  PRACTICAL 

HISTOLOGY.     For  Beginners  in  Microscopy. 
Cloth,  price  $1.00;  interleaved  $1.50. 


IN  PREPARATION. 

A  TREATISE  ON  DISEASES  OF  THE   KIDNEYS,  with 
especial  reference  to  Pathology  and  Therapeutics. 


A    GUIDE 

TO  THE 

PRACTICAL    EXAMINATION 

OF 

URINE. 

FOR  THE  USE  OF  PHYSICIANS  AND  STUDENTS. 

BY 
JAMES  TYSON,  M.D., 


OF  PHYSICIANS,  PHILADELPHIA, 
ETC.  ETC.  ETC. 


SECOND    EDITION, 

KEVISED  AND  IMPROVED, 

WITH  ILLUSTRATIONS. 


PHILADELPHIA: 
LINDSAY   AND    BLAKISTON. 

1878. 

Jane  and  Kenneth  Mackenzie 
879  Cornish  Drive 
San  Diego,  California  92107 
U.S.A.,  Planet  Earth 


Entered  according  to  Act  of  Congress,  in  the  year  1878,  by 

LINDSAY    AND    BLAKISTON, 
In  tbe  Office  of  the  Librarian  of  Congress,  at  Washington,  D.  C. 


PHILADELPHIA: 


PREFACE  TO  THE  SECOND  EDITION. 


ADVANTAGE  has  been  taken  of  the  occasion  for  a  new 
edition  of  this  little  work,  to  carefully  correct  the  pre- 
vious one,  as  well  as  to  improve  it  by  incorporating  such 
additions  of  new  facts  and  processes  as  seemed  consistent 
with  its  original  purpoae,  without,  however,  increasing 
the  size  of  the  book.  This  has  been  accomplished  by 
slightly  increasing  the  amount  of  matter  on  each  page. 

It  is  hoped  that  it  may  prove  worthy  of  the  same 
kindly  reception  accorded  its  predecessor. 


1506,  SPRUCE  STREET, 
Sept.  1,  1878. 


PREFACE  TO  THE  FIRST  EDITION. 


DOUBTLESS  it  will  be  thought  by  some  that  there  is  no 
present  necessity  for  an  additional  volume  on  the  subject 
which  the  title  of  this  pretends  to  cover.  Such  was, 
indeed,  the  writer's  own  impression,  when  urged,  a  few 
months  ago,  to  prepare  it.  Some  reflection,  however, 
convinced  him  that,  while  there  were  quite  a  number  of 
comprehensive  works  of  great  value,  and  a  smaller  num- 
ber of  manuals  or  guides  for  the  examination  of  urine, 
the  latter  seemed  altogether  too  limited,  Avhile  the  former 
are  too  bulky  to  be  convenient  for  daily  use.  It  was 
further  thought  that  an  experience  of  several  years  in 
almost  daily  microscopical  and  chemical  examinations  of 
urine  for  others  and  himself,  as  well  as  in  teaching  the 
subject  in  the  University  of  Pennsylvania,  had  given  the 
author  such  familiarity  with  the  practical  wants  of  the 
physician,  as  would  appear  to  justify  his  attempting  to 
supply  them  in  a  convenient  shape. 

Pains  have  been  taken  to  secure  a  completeness  of 


Vlll  PREFACE. 

illustration  not  usual  in  the  smaller  works,  while  the 
methods  for  the  most  exact  quantitative,  as  well  as 
approximate  analysis,  have  been  included,  without  too 
much  increasing  the  size  of  the  volume. 

The  modes  of  approximate  estimation  so  commonly 
used  in  the  German  laboratories,  it  is  believed  are  here 
published  for  the  first  time  in  English.  For  the  details 
of  these  the  writer  is  indebted  to  the  admirable  practical 
treatise  of  Hoffmann  and  Ultzmann,  so  often  referred  to 
in  the  text.  To  Messrs.  Lindsay  &  Blakiston  acknowl- 
edgment is  due  for  the  privilege  of  using  electrotypes  of 
certain  cuts  in  the  American  edition  of  Dr.  George 
Harley's  work  "  On  the  Urine  and  its  Derangements," 
and  to  Dr.  C.  B.  Nancrede  for  assistance  in  drawing  and 
coloring. 


PRACTICAL  EXAMINATION  OF  URINE, 


SECRETION  OF  URINE. 

THE  theory  which  explains  the  secretion  of  urine  most 
consistently  with  the  facts,  is  one  which,  while  it  makes  it 
mainly  physical,  admits  something  also  of  the  nature  of  ela- 
boration in  the  acts  of  the  kidney.  Nothing  can  be  more 
beautiful  at  first  thought  than  the  theory  of  Ludwig,  accord- 
ing to  whom  the  process  is  a  purely  physical  one — partly  a 
transudation  and  partly  a  diffusion  or  osmosis.  He  correctly 
states  that  in  the  capillaries  of  the  malpighian  bodies  there 
is  a  greatly  increased  blood  pressure  caused  by  the  resistance 
to  the  exit  of  the  blood  through  the  efferent  vessel.  As  the 
result  of  this,  a  transudation  of  the  watery  constituents  of 
the  blood,  with  some  dissolved  salts,  takes  place  into  the 
malpighian  capsule.  Thus  the  blood  is  greatly  thickened 
when  it  reaches  the  second  capillary  system  surrounding  the 
convoluted  tubules  which  contain  the  thin  aqueous  transuda- 
tion from  the  malpighian  bodies.  "Here  we  have,  then,  the 
essential  elements  of  a  complete  osmometer — an  animal  mem- 
brane formed  by  the  thin  wall  of  the  capillary  and  the  delicate 
basement-membrane  of  the  tubule,  with  a  dense  fluid  (the 
blood)  on  one  side,  and  a  thin  saline  solution  on  the  other.  An 
interchange  now  takes  place,  as  the  result  of  which  a  current 
2 


14        PEACTICAL   EXAMINATION   OF   THE   URINE. 

sets  in,  of  the  water  from  the  tubules  to  the  blood,  and  of  the 
products  of  regressive  metamorphosis,  urea,  etc.  and  salts  to 
the  tubules,  concentrating  the  fluid  in  the  latter,  making  it, 
in  other  words,  urine ;  while  the  albuminous  constituents  of 
the  blood  are  retained  there  because  of  their  well-known 
resistance  to  osmosis. 

One  important  fact,  however,  remains  unaccounted  for  by 
this  theory,  beautifully  simple  as  it  is.  This  is,  that,  if  the 
tubules  are  stripped  of  their  epithelium,  as  they  often  are  in 
disease,  urea  and  other  products  of  regressive  metamorphosis 
are  no  longer  so  freely  removed,  but  accumulate  in  the  blood, 
producing  the  phenomena  of  urcp.mia,  so  called.  We  must 
therefore  admit  some  elaborating  action  on  the  part  of  the 
epithelium  through  which  these  results  are  obtained.  Doubt- 
less, however,  the  larger  proportion  of  the  act  is  a  physical 
one — a  process  of  transudation  or  filtration  and  of  diffusion 
or  osmosis. 

The  objection  formerly  made  to  the  physical  nature  of  the 
act  of  secretion  of  urine,  on  the  ground  that  we  cannot  by 
this  method  account  for  the  formation  of  an  acid  fluid  from 
an  alkaline  one,  no  longer  holds,  since  Dr.  Ralfe,  of  London, 
has  shown  this  to  be  quite  possible.  Into  one  limb  of  a  small 
U-shaped  tube,  fitted  with  a  membranous  diaphragm  at  the 
bend,  he  introduced  an  alkaline  solution  of  sodium  bicarbon- 
ate, and  into  the  other  limb  a  solution  of  neutral  sodium 
phosphate.  He  then  passed  a  weak  electric  current  through 
the  solutions.  In  a  short  time  the  fluid  in  the  limb  connected 
with  the  positive  pole  became  acid  from  the  formation  of  acid 
sodium  phosphate,  the  substance  which  is  the  chief  agent  in 
producing  the  acid  reaction  of  the  urine,  while  the  fluid  in 
the  limb  connected  with  the  negative  pole  increased  in 


REAGENTS   AND   APPARATUS   REQUIRED.  15 

alkalinity.     The  changes  are  represented  by  the  following 
formula  :  — 

Sodium  Neutral  sodium          Sodium  Acid  sodium 

bicarbonate.  phosphate.  carbonate.  phosphate. 


NaHCO3  -f  Na2HPO4  =  Na2CO, 


REAGENTS  AND  APPARATUS  REQUIRED  FOR  QUALITATIVE 
AND  APPROXIMATE  ANALYSIS.f 

It  is  not  a  matter  of  very  great  importance  in  what  form 
of  bottle  Reagents  are  kept.  They  should  hold  enough  —  four 
ounces  is  a  convenient  quantity  —  and  be  provided  with 
ground-glass  stoppers  for  the  acids,  but  the  alkalies  are  bet- 
ter kept  in  bottles  with  rubber  stoppers.  Those  required 
are  as  follows  :  — 

1.  Pure  colorless  nitric  acid  (HN03). 

2.  Nitroso-nitric  acid,  the  brown  fuming  nitrous  acid  of  commerce, 

really  nitric  acid  containing  nitrogen  tetroxide  (HNOj-j-NjC^ 
or  N0.2). 

3.  Pure  hydrochloric  acid  (HC1). 

4.  Pure  colorless  sulphuric  acid  (H2S04). 

5.  Pure  acetic  acid  (C2H4O2). 

6.  Liquor  potassse,  U.  S.  P.     The  sp.  gr.  is  1065,  and  it  contains 

5T8^  per  cent,  of  potassium  hydroxide  (HKO). 

7.  Solution  of  caustic  potash,  or  caustic  soda,  1  part  to  2  of  dis- 

tilled water,  sp.  gr.  1330-f-,  to  be  spoken  of  in  the  text  as 
the  "stronger  solution  of  potash."  It  is  the  setzkalilauge 
(or  setznatronlauge  if  soda)  of  the  German  Pharmacopoeia, 
and  contains  from  .30  to  .31  of  the  hydrate  of  potassium  (or 
of  sodium). 

8.  Solution  of  sodium,  carbonate,  1  part  water  and  3  parts  of  the 

crystallized  salt. 

*  Medical  News  and  Library,  Oct.  1871,  from  London  Lancet,  July 
1,  1871. 

f  All  reagents  and  apparatus  suitable  for  urinary  analysis  may 
be  obtained  of  Bullock  &  Crenshaw,  528  Arch  Street,  Philadelphia. 


16         PRACTICAL   EXAMINATION    OF   THE    URINE. 

9.  Solution  of  barium  chloride,  4  parts  crystallized  barium  chlo- 
ride, 16  of  distilled  water,  and  one  of  hydrochloric  acid. 

10.  Liquor  ammonife,  U.  S.  P. 

11.  The  magnesian  fluid,  containing  of  magnesium  sulphate  and  pure 

ammonium  chloride,  each  1  part,  distilled  water  8  parts,  and 
pure  liquor  ammonias  1  part. 

12.  Solution  of  copper  sulphate,  say  1  gramme  to  30  c.  c.  or  15  grs. 

tofjj. 

13.  Pavy's  or  Fehling's  copper  solutions,  made  as  directed  under 

volumetric  analysis  for  sugar. 

14.  Solution  of  silver  nitrate,  1  part  to  8  of  distilled  water. 

15.  Solution  of  lead  acetate  (sugar  of  lead),  1  part  to  4  of  distilled 

water. 

16.  Solution  of  basic  lead  acetate,  1  part  to  4  distilled  water. 

17.  Distilled  water,  a  litre  or  a  quart. 

18.  Alcohol,  95  per  cent.,  a  half  litre  or  a  pint. 
Other  solutions  as  required. 

Apparatus. 
A  note  and  drawing-book. 

1  dozen  test-tubes,  assorted  sizes,  some  narrow.     (Some  test-tubes, 

with  bases,  so  that  they  may  stand  on  a  shelf  or  mantel,  are 
convenient  and  desirable  ;  see  Fig.  4).  A  couple  of  these 
•  may  be  graduated  in  decimetre  and  centimetre  divisions,  and 
thus  serve  as  fluid  measures,  and  at  the  same  time  be  used 
to  measure  the  proportion  of  a  sediment,  or  of  albumen  after 
the  heat  test  and  subsidence. 

Test-tube,  rack,  and  drainer. 

4  conical  glasses.  (Observe  that  they  taper  toward  a  point,  and 
that  there  is  not  a  convexity  at  the  bottom.) 

2  or  3  smooth  wineglasses,  with  broad  bottoms,  of  the  kind  some- 

times known  as  "collamore"  wineglasses. 
Red  and  blue  litmus-paper  ;  filtering-paper.- 
Urinometer  and  urinometer  glass. 
4  ground-glass  covers,  assorted  sizes. 
Spirit-lamp. 

3  porcelain  capsules. 

6  beaker  glasses,  small  and  medium  sizes. 
£  dozen  watch-glasses. 


SELECTING   A   SPECIMEN   OF   UKINE.  17 

3  glass  funnels,  assorted  sizes. 

Glass  stirring-rods  and  dropping-tubes. 

1  large  receiving-glass  to  measure  twenty-four  hours'  urine,  with 
capacity  of  2000  cubic  centimetres  or  more. 

1  graduated  measuring-glass  holding  500  c.  c. 

1  wash-bottle  with  distilled  water. 

1  retort  stand  ;  water-bath. 

1  or  2  sheet-iron  tripods  with  wire  gauze  to  cover. 

1  100-minim  pipette  ;  1  volume  pipette  for  5  c.  c.,  another  for  10  c.  c. 

Platinum  spoon. 

Blowpipe. 

Swabs  for  cleaning  test-tubes,  etc. 

A  microscope  with  two  object-glasses,  a  ^  or  \  inch,  and  a  1  inch 
or  T8^  inch  ;  stage  micrometer  :  camera  lucida  for  drawing  ; 
glass  slides,  thin  covers,  shallow  cells;  test-bottles  with  capil- 
lary stoppers  ;  plain  glass  pipettes. 

For  volumetric  analysis  are  required  in  addition — 

A  full  set  of  volume  pipettes,  5,  10,  15,  20,  30,  50  c.c. 

1  graduated  dropping  pipette,  20  c.  c. 

2  burettes  of  50  c.  c.  capacity. 
A  half-litre  flask. 

Volumetric  solutions  as  directed  under  volumetric  analysis. 

If  the  solutions  are  made  by  the  student  himself,  as  they 
may  be,  he  should  be  provided  with  a  balance  which  will 
turn  with  a  milligramme,  or  with  ^th  of  a  grain  if  the 
English  system  is  used. 


SELECTING  A  SPECIMEN  OF  URINE. 

In  obtaining   a   specimen    of  urine   for   examination,  it 
should,  as  far  as  possible,  be    a  part  of  the  whole  twenty- 
four  hours'  urine,  as  the  specific  gravity,  reaction,  and  other 
properties  are  well  known  to  vary  during  the  twenty-four 
2* 


18 


PRACTICAL   EXAMINATION   OF   THE    URINE. 


hours,  and  the  only  accurate  method 
is  therefore  to  take  a  part  of  the 
total.  But  as  this  is  not  always  pos- 
sible, a  portion  of  that  passed  in  the 
morning  before  breakfast  is  generally 
most  suitable.  And  yet  this  is  not 
always  the  case.  Thus,  when  a  small 
quantity  of  albumen  is  present  in 
urine,  it  is  often  increased  after  a 
meal,  and  sometimes  when  there  is 
no  trace  apparent  in  the  morning 
urine,  a  little  will  be  found  detectable 
after  a  meal.  The  same  is  true  of 
sugar.  In  Fig.  1  are  represented 
forms  of  glass  vessels  used  for  mea- 
suring large  quantities  of  urine. 


GENERAL   PHYSICAL    AND    CHEMICAL    CHARACTERS  OF  THE 
URINE. 

Normal  urine  may  be  described  as  a  transparent,  aqueous 
fluid,  of  a  pale  yellow  (or  amber)  hue,  acid  reaction,  specific 
gravity  of  about  1020  when  passed  in  the  average  quantity 
of  1500  cubic  centimetres  (50  ounces)  in  the  twenty-four 
hours,  and  possessing  an  odor  which  can  only  be  described 
as  "  characteristic"  or  "  urinous."  The  odor  is  sometimes 
spoken  of  as  "aromatic." 

Each  one  of  these  characters  is,  however,  liable  to  some 
variation  within  the  limits  of  health,  as  well  as  disease,  and 
with  these  variations  we  should  be  thoroughly  familiar  before 
interpreting  a  given  specimen. 

I.  As  to  Transparency — This,  although  quite  constant, 


PHYSICAL   AND   CHEMICAL   CHARACTERS.  19 

can  scarcely  be  considered  an  essential  character  of  normal 
urine,  while,  on  the  other  hand,  it  by  no  means  follows  that 
because  a  given  specimen  of  urine  is  transparent,  it  is  there- 
fore normal. 

Causes  of  Diminished  Transparency — Diminished  trans- 
parency may  be  due  to  one  of  three  causes.  1.  Even  urine 
which  is  apparently  perfectly  transparent  when  passed,  com- 
monly exhibits,  a  few  minutes  after  standing,  a  faint  cloud 
floating  somewhere  between  the  top  and  bottom,  which  is 
composed  of  mucus  derived  from  the  genito-urinary  tract. 
Mucus  itself  is  also  transparent,  but  becomes  visible  through 
the  presence  of  so-called  mucus-corpuscles  and  epithelium  in 
different  stages  of  growth,  discoverable  by  microscopic  exa- 
mination. In  the  urine  of  females,  this  cloud  is  apt  to  be 
more  distinctly  visible  in  consequence  of  the  increased  amount 
of  epithelium  from  the  vagina,  and  general  increased  area  of 
the  mucus-surfaces  in  this  sex.  There  is  nothing  abnormal 
in  the  presence  of  such  an  amount  of  mucus  as  is  covered  by 
the  above  description.  The  effect  of  alkalies,  heat,  and  strong 
acids  is  to  leave  the  appearance  unchanged,  but  acetic  acid 
may  produce  a  slight  increase  of  the  opacity  by  coagulating 
the  mucin. 

2.  Normal  acid  urine  may  be  partially  opaque  at  the 
moment  when  passed  by  reason  of  the  presence  of  the  earthy 
phosphates  of  lime  and  magnesia.  These  shortly  after  pass- 
ing begin  to  subside,  and  within  half  an  hour  present  an  ap- 
pearance not  unlike  that  of  mucus — that  of  a  flocculent  mass 
floating  somewhere  between  the  top  and  bottom  of  the  vessel. 
But  still  later,  generally  within  an  hour,  it  has  approached 
the  bottom  and  become  a  sediment,  cloudy  and  bulky,  but 
leaving  a  transparent  supernatant  fluid.  The  test  of  its  na- 
ture is  the  addition  of  a  few  drops  of  any  acid,  as  nitric, 


20        PRACTICAL   EXAMINATION   OF   THE   URINE. 

which  will  cause  a  prompt  disappearance  of  the  sediment,  if 
it  be  the  earthy  phosphate,  while  the  application  of  heat  will 
increase  it,  such  increase  being  also  rapidly  dissipated  by  the 
action  of  acid. 

The  more  or  less  constant  presence  of  the  earthy  phos- 
phates above  mentioned  cannot  be  considered  abnormal. 
Requiring  an  acid  urine  to  keep  them  in  solution,  a  diminu- 
tion of  the  degree  of  acidity  may  result  in  their  precipitation, 
which  is  further  increased  by  an  alkaline  reaction.  Such 
diminished  acidity  and  substitution  of  alkalinity  always  takes 
place  during  digestion,  and  the  deposit  is  therefore  at  such 
time  commonly  observed. 

3.  Urine  is  sometimes  rendered  turbid  by  the  presence  of 
the  so-called  mixed  urates  of  soda,  potash,  lime,  and  mag- 
nesia. The  most  frequent  cause  of  this  precipitation  in 
normal  urine,  is  a  reduction  in  the  temperature  of  the  urine 
after  being  passed.  Although  highly  soluble  in  water  at  the 
temperature  of  the  body,  the  urates  are  promptly  precipitated 
from  a  cold  urine,  such  as  would  prevail  in  a  room  without 
fire  on  a  winter's  morning. 

As  in  the  case  of  earthy  phosphates,  such  opacity  soon 
diminishes  by  subsidence  of  the  disseminated  urates,  which 
become  a  white  or  pink-  deposit,  occupying  less  bulk  than 
phosphates  ;  they  are  also  apt  to  be  precipitated  on  the  sides 
of  the  vessel.  The  test  of  its  nature  is  the  application  of 
heat,  which  quickly  causes  its  dissipation,  while  a  deposit  of 
phosphates  is  increased  by  heat. 

Pathologically,  urine  may  be  opaque  or  semi-opaque  from 
abnormal  degrees  of  the  above  conditions,  or  from  the  pre- 
sence of  pus,  which  also  subsides  with  a  rapidity  inversely 
as  the  quantity  of  mucus.  If  the  latter  is  absent,  or  present 
in  small  quantity,  the  subsidence  is  rapid;  if,  on  the  other 


PHYSICAL    AND    CHEMICAL    CHARACTERS.  21 

hand,  it  is  large,  subsidence  is  slow,  often  requiring  several 
hours.  The  opacity  of  such  urine  is  increased  by  the  appli- 
cation of  heat  and  acids,  in  consequence  of  the  precipitation 
of  the  albumen  which  is  always  a  constituent  of  liquor  puris. 

II.  As  to  Consistence In  health,  urine  is  never  anything 

else  but  aqueous,  that  is,  dropping  and  flowing  readily. 

Pathologically,  it  often  becomes  viscid,  glutinous,  and 
with  difficulty  or  not  at  all  separable  into  drops.  Such 
state  may  be  due  to  the  presence  of  an  excess  of  pure  mucus, 
or  of  a  mixture  of  mucus  and  pus,  and  very  frequently  it  is 
caused  by  the  action  upon  pus  of  an  alkalinity  due  to  the 
presence  of  ammonium  carbonate,  to  be  again  alluded  to. 

In  the  so-called  chylous  urine  of  tropical  countries,  also 
sometimes  met  here,  there  is  an  addition  of  molecular  fat, 
giving  a  chylous  appearance  to  the  urine,  and  an  increased 
consistence. 

III.  As  to  Color. — While  normal  urine  may  be  character- 
ized in  general  terms  as  pale  yellow,  or  amber  lined,  there 
may  be  considerable  variation  in  health.     Due  to  the  pres- 
ence in  solution  of  the  normal  coloring  matters,  it  is  deeper 
or  paler  according  to  the  proportion   of  water  dissolving 
them.     After  copious  libations  of  beer  or  water,  the  quantity 
of  urine  discharged  being  large,  the  color  is  very  pale.     On 
the  other  hand,  circumstances  which  diminish  the  proportion 
of  water  within  the  limits  of  health  deepen  the  color.     The 
complemental  relation  of  the  skin  and  kidneys  is  well  known. 
Under  the  influence  of  warmth,  therefore,  when  the  skin  is 
acting  freely,  the  quantity  of   urine  is   smaller,  and  it  is 
darker.     In  winter,  the  skin  being  less  active,  the  quantity 
of  urine  is  larger,  and  its  color  less  deep.     In  persons  from 
whom   the  respiratory  exhalation   is   greater,  the   urine   is 
likewise  less  abundant,  darker,  and  vice  versa. 


22        PRACTICAL   EXAMINATION   OF   THE   URINE. 

Pathologically,  the  color  of  urine  may  be  altered  by  in- 
crease or  diminution  of  the  normal  coloring  matters,  or  by 
the  addition  of  abnormal  ones. 

1.  The  former  is  also  generally  due  to  a  change  in  the 
proportion  of  the  coloring  matters  to  the  watery  constituents. 
Thus  we  have  almost  an  absence  of  color  in  the  copious 
urines  of  diabetes,  hysteria,  and  convulsions,  while  we  have 
a  high  color  in  the  urine  of  fevers  and  febrile  states,  chiefly 
because  the  quantity  of  water  is  diminished,  but  in  the  latter 
instance  also  because  of  the  addition  of  an  abnormal  coloring 
matter,  known  as  uroerythrin. 

2.  The  addition  of  abnormal  coloring  matters  is  seen  in 
the  instance  just  mentioned  (fevers),  in  urines  containing 
blood  or  blood-coloring  matters  and  bile-pigment ;  and  in  the 
blue  and  brown  urines,  of  which  several  instances  have  been 
reported. 

3.  The  urine  is  also  colored  after  the  ingestion  of  certain 
vegetable  matters  eliminated  by  the  kidneys,  as  santonin, 
which  imparts  a  yellow  color. 

IV.  The  Reaction  of  normal  mixed  urine,  that  is,  the  urine 
of  the  entire  twenty-four  hours,  is  always  acid.  And,  gen- 
erally, specimens  of  urine  passed  at  any  time  of  day  exhibit 
this  reaction,  though  there  is  a  difference  in  its  degree,  while 
after  a  meal  the  urine  may  become  neutral  or  even  alkaline. 

The  cause  of  this  change  in  the  reaction  is  still  disputed. 
Roberts  believes  that  it  is  due  to  an  admixture  with  the 
blood,  of  the  elements  of  food,  which  are  largely  alkaline, 
and  that  the  resulting  increased  alkalinity  affects  the  reac- 
tion of  the  urine  secreted.  Bence  Jones  contends,  that  it  is 
the  demand  made  on  the  blood  for  the  elements  of  the  acid 
gastric  juice,  which  thus  affects  the  reaction  of  the  urine 
secreted  during  digestion.  While  neither  explanation  is 


PHYSICAL   AND   CHEMICAL   CHARACTERS.          23 

altogether  satisfactory,  the  former  seems  more  likely  to  be 
correct. 

The  cause  of  the  acid  reaction  of  the  urine  is  usually 
ascribed  to  acid  sodic  phosphate,  though  it  is  probably  also 
slightly  contributed  to  by  other  acid  constituents,  as  uric 
and  hippuric  acids,  and  under  certain  circumstances,  also 
by  lactic  and  acetic  acids. 

There  is  often  observed  in  m-ine  which  has  been  standing 
for  a  short  time,  especially  at  a  moderate  temperature,  an 
increased  degree  of  acidity,  which  sometimes  results  in  a 
decomposition  of  urates,  and  a  precipitation,  first  of  acid 
unites,  and  later  of  uric  acid  crystals.  This  has  been  as- 
cribed by  Scherer  to  an  acid  fermentation,  in  which,  the 
mucus  acting  as  the  ferment,  lactic  and  acetic  acids  are 
formed  by  the  decomposition  of  the  coloring  matters  of  the 
urine.  This  lias  not  been  altogether  satisfactorily  proven, 
while  the  increased  acidity  is  by  no  means  constant. 

It  is  certain,  however,  that  acid  urine  which  has  stood 
for  some  time,  and  more  rapidly  in  hot  weather,  exhibits  an 
amrnoniacal  odor,  and  becomes  alkaline  in  its  reaction ;  at- 
tending this  change  of  reaction  results  a  semi-opacity  with 
a  precipitation  of  a  white  amorphous  and  crystalline  sedi- 
ment, and  often  also  with  the  formation  of  an  iridescent 
pellicle  on  the  surface.  The  cause  of  these  changes  has  been 
well  determined,  and  has  already  been  alluded  to.  Through 
the  action  of  mucus  and  other  organic  matters  acting  in  their 
decomposition  as  a  ferment,  the  urea  is  converted  into 
ammonium  carbonate  by  the  addition  of  two  equivalents  of 
water.  Thus : — 

CH+N2O  +  2H2O  =  (NH4)2CO3, 

which  gives  the  odor  of  ammonia  and  the  alkaline  reaction. 
The  opacity  and  deposits  are  due  to  the  precipitation  of 


24        PRACTICAL   EXAMINATION   OF   THE   URINE. 

the  crystalline  triple  phosphate  of  ammonium  and  magne- 
sium, the  amorphous  phosphate  of  lime,  urate  of  ammonium, 
and  to  living  vegetable  organisms  known  as  bacteria. 

V.  The  Specific  Gravity  as  stated  may  be  put  down  at 
1020  for  an  average  amount  of  1500  c.  c.  (50  oz.)  in  the 
twenty-four  hours.  But  as  this  amount  is  by  no  means 
fixed,  while  the  amount  of  solid  matter  remains  about  the 
same,  the  specific  gravity  must  vary  accordingly.  Under 
the  influence  of  cold,  when  the  skin  is  not  acting,  and  after 
copious  use  of  water  and  diuretics,  the  specific  gravity  may 
descend  to  1010  and  even  lower,  within  the  limits  of  health. 
But,  where  perspiration  is  copious,  or  a  drain  of  water  from 
the  economy  takes  place  through  some  other  channel,  the 
urine  becomes  concentrated,  and  may  be  1025  or  more  in 
specific  gravity. 

Pathologically,  the  specific  gravity  of  urine  is  increased 
or  diminished,  but  to  be  entirely  reliable,  conclusions  should 
be  based  upon  observations  made  on  the  entire  quantity 
passed  in  the  twenty-four  hours.  The  specific  gravity  is 
increased  in  diabetes  mellitus,  where  it  sometimes  reaches 
1050.  A  specific  gravity  of  more  than  1028,  if  it  attend  a 
copious  urine,  should  excite  suspicion  of  diabetes,  and  calls 
for  sugar  tests.  In  a  single  instance  which  came  under  my 
observation,  a  specific  gravity  of  1020,  in  a  specimen  of 
urine,  was  attended  by  the  evident  presence  of  sugar,  easily 
shown  by  all  the  tests.  The  case  was  that  of  a  medical 
practitioner  aged  forty-five.  On  a  selected  diet,  the  sugar 
disappeared  altogether,  while  the  specific  gravity  descended 
to  1018;  proving  that  it  is  not  safe  to  infer,  from  a  low 
specific  gravity  alone,  the  absence  of  sugar,  although  I  have 
never  found  it  in  urine  having  a  lower  specific  gravity  than 
1020. 


PHYSICAL    AND    CHEMICAL    CHARACTEBS. 


25 


The  specific  gravity  is  also  increased  in  the  first  stage  of 
the  acute  fevers,  in  consequence  of  the  increased  amount  of 
solid  matters  excreted ;  and  in  the  first  stage  of  acute 
Bright's  disease,  from  the  presence  of  blood,  the  higher 
specific  gravity  of  the  latter  raising  that  of  the  mixed  fluid. 
The  specific  gravity  is  diminished  in  hysterical  and  spasmo- 
dic hydruria,  though  here  it  attends  a  proportionate  increase 
of  water  and  is  not  of  much  practical  significance.  In  all 
forms  of  Bright's  disease,  except  the  stage  of  acute  nephritis 

Fro.  2.     (From  Harley.) 


referred  to,  there  is  a  tendency  to  lowering  of  specific  gravity 
from  the  diminished  proportion  of  urea.  Particularly  is  such 
redaction  of  specific  gravity  significant  when  it  attends  a 
diminished  quantity  of  urine.  In  a  general  way,  the  pres- 
ence of  albumen  and  sugar  being  eliminated,  variations  in 
3 


26        PRACTICAL  EXAMINATION   OF   THE   URINE. 

the  specific  gravity  of  urine  point  to  variations  in  the  amount 
of  urea  present;  lower  specific  gravity  of  mixed  urine 
generally  means  less  urea. 

To  determine  specific  gravity,  the  so-called  urinometer  is 
almost  invariably  used,  and  though  less  accurate  than  the 
picnometer  (E,  Fig.  2)  and  balance,  is  still  sufficiently  so 
when  carefully  constructed.  Every  urinometer  should  first 
be  tested  with  distilled  water  at  60°  F.  (15.54°  C.),  into 
which  it  should  sink  to  the  mark  0  or  1000.  In  their 
graduation  the  lines  indicating  the  degrees  should  gradually 
approach  each  other  as  the  bulb  is  reached,  because  allow- 
ance must  be  made  for  the  weight  of  the  stem  above  water. 
The  English-made  urinometers,  about  5  inches  long  (Fig. 
2  c),  are  generally  accurate,  but  the  short  German  instru- 
ments (3  inch)  are  very  convenient  for  small 
quantities  of  urine.  In  the  little  urinometer 
-gl  of  Heller  (Fig.  3),  much  used  in  Vienna,  in 
which  the  "  sink"  consists  of  leaden  shot,  the 
graduation  of  Baume  is  retained,  where  one 
degree  corresponds  with  seven  of  the  ordinary 
9  scale.  Thus  1001  =  1007,  1002  =  1014, 
and  so  on.  Especial  care  should  be  taken  in 
testing  these  instruments,  as  a  slight  variation 
in  them  indicates  a  large  one  by  the  ordinary 
scale.  The  writer  has  in  his  possession  an  instrument  of 
this  kind  which  recorded  the  specific  gravity  of  a  given 
specimen  of  urine  1004,  that  is,  1028  by  the  ordinary  scale, 
of  which  the  specific  gravity  by  a  long-tried  English  instru- 
ment was  found  to  be  1019.  And  on  testing  the  former 
with  distilled  water,  it  was  found  to  sink,  not  to  1000,  but 
to  1001 -f,  proving  its  inaccuracy.  More  recently  a  urino- 
meter has  been  imported  from  Germany  even  slightly  shorter 


PHYSICAL   AND   CHEMICAL   CHARACTERS.          27 

than  the  original  of  Heller,  in  which  the  ordinary  scale  is 
retained  on  an  ivory  stem  within  the  tube,  and  the  "  sink" 
contains  mercury  instead  of  shot,  apparently  altogether  more 
carefully  made.  These,  so  far  as  tested  by  myself,  have 
been  found  accurate. 

The  cylindrical  glass  vessel  usually  supplied  with  the  urino- 
meter,  or  a  sufficiently  large  test-tube,  should  be  about  three- 
fourths  filled,  the  urinometer  introduced,  and  when  at  rest,  the 
specific  gravity  read  off.  The  cylinder  or  test-tube  should 
not  be  too  small  in  relation  to  the  urinometer,  lest,  in  conse- 
quence of  the  capillary  attraction  between  the  latter  and  the 
walls  of  the  cylinder,  the  urinometer  should  not  sink  as  low 
as  it  ought.  For  the  same  reason  the  urinometer  should  not 
be  allowed  to  impinge  against  one  side  of  the  glass.  If  the 
quantity  of  urine  be  too  small  sufficiently  to  fill  the  cylinder, 
it  may  be  diluted  with  a  quantity  of  distilled  water  sufficient 
to  fill  the  cylinder  to  the  required  height.  From  the  sp. 
gr.  of  this  mixture  may  be  calculated  that  of  the  urine. 
Thus,  suppose  it  is  necessary  to  add  four  times  as  much 
water  as  urine  to  enable  us  to  use  the  urinometer,  that  is,  to 
make  five  volumes,  and  the  specific  gravity  of  the  mixed 
fluid  is  1004,  then  that  of  the  urine  would  be  1000-j-(4x5)= 
1020. 

VI.  Quantity The  average  amount  of  urine  in  the 

twenty-four  hours  is  put  down  at  1500  c.  c.,  or  about  50 
fluidounces.  But  enough  has  already  been  said  to  allow 
the  inference  that  there  is  also  much  variation  within  the 
limits  of  health.  All  that  has  been  said  of  color  and  specific 
gravity  in  this  respect  is  true  of  the  quantity  of  urine, 
though  in  an  inverse  ratio.  That  is,  in  health,  diminished 
intensity  of  color  and  diminished  specific  gravity  correspond 
with  increased  quantity  of  urine.  It  is  with  regard  to  quan- 


28        PKACTICAL   EXAMINATION   OF   THE   UEINE. 

tity  that  the  complemental  relation  so  well  known  to  exist 
between  the  skin  and  kidneys  most  palpably  shows  itself,  the 
increased  action  of  the  former  causing  diminished  quantity 
of  water  separation  by  the  latter,  and  vice  versa.  In  de- 
ranged conditions,  it  is  the  absence  of  this  relation  of  color 
and  specific  gravity  to  quantity  which  gives  significance  to 
either. 

Pathologically,  the  quantity  of  urine  is  increased  in 
diabetes,  and  hysterical  and  convulsive  conditions,  in  the 
former,  however,  with  increased  specific  gravity,  and  in  the 
latter  with  diminished.  In  cardiac  hypertrophy,  in  common 
with  all  conditions  of  increased  blood-pressure,  in  which  we 
include  ingestion  of  large  amounts  of  water,  the  peripheral 
action  of  cold,  etc.,  there  is  an  increase  of  water,  and  a  cor- 
responding reduction  in  specific  gravity  and  color. 

In  all  forms  of  Bright's  disease,  except  in  the  cirrhotic 
and  albuminoid  kidneys,  there  is  a  tendency  to  diminished 
secretion  of  urine.  Towards  the  fatal  termination,  however, 
it  is  diminished  even  in  these  affections.  Any  marked 
diminution  of  urine  in  these  affections,  particularly  if  it  be 
attended  by  a  low  specific  gravity,  which  means  diminished 
urea,  becomes  a  grave  symptom. 

In  acute  fevers  and  inflammatory  affections,  the  quantity 
of  urine  is  very  constantly  diminished  until  convalescence 
sets  in,  when  there  is  generally  observed  a  marked  increase 
in  the  secretion  of  urine,  which,  in  common  with  the  profuse 
perspiration  often  observed  at  the  same  time,  was  long  ago 
characterized  by  the  word  "critical." 

VII.  Of  the  Odor,  little  more  can  be  said  than  that  it  is 
"peculiar"  or  "characteristic"  in  health.  It  is  by  some 
spoken  of  as  "aromatic."  There  is,  however,  appreciable 
difference  in  its  intensity,  as  most  have  observed  in  their 


SOLID    MATTERS.  29 

own  cases.  Concentrated  urines  always  exhibit  what  is 
described  in  common  language  as  "strong  odor."  This  is 
undoubtedly  due  to  urea,  though  the  peculiar  odor  of  urine  is 
not  ascribed  to  urea,  but  rather  to  the  minute  quantities  of 
phenylic,  taurylic,  and  damoluric  acid  which  are  found  in  it. 

Urine  which  has  been  standing  exposed  in  warm  weather 
acquires  an  odor  which  is  at  once  putrescent  and  ammoniacal, 
the  former  from  decomposition  of  mucus  and  other  organic 
matters,  the  latter  from  the  ammonium  carbonate  derived 
from  the  urea.  The  former  is  predominant  when  a  large 
amount  of  organic  matter  is  present,  and  is  often  observed 
in  destructive  disease  of  the  kidney  or  its  pelvis,  and  espe- 
cially of  the  bladder. 

The  odor  of  urine  is  very  promptly  influenced  by  that  of 
substances  separated  by  the  kidney  from  the  blood,  illustrated 
by  the  well-known  phenomenon  of  the  odor  of  violets  in  the 
urine  of  persons  taking  turpentine.  The  odor  of  cubebs, 
copaiba,  and  sandalwood  oil  is  promptly  communicated  to 
the  urine  of  persons  taking  them.  So,  too,  the  use  of  cer- 
tain vegetable  foods  promptly  influences  the  odor  of  the 
urine.  Among  these  asparagus  is  prominent. 

In  disease,  except  the  increased  intensity  of  the  character- 
istic odor  in  concentrated  urines,  the  putridity  alluded  to, 
and  a  sweetish  smell  which  often  attends  the  presence  of  sugar 
in  the  urine,  there  seem  to  be  no  modifications  of  this  "  cha- 
racteristic" odor  of  urine. 

To  Determine  the  amount  of  Solid  Matters  in  the  Twenty- 
four  hours'  Urine. 

Knowing  the  quantity  of  urine  passed  in  the  twenty-four 
hours,  and  its  specific  gravity,  an  approximation  to  the 

8* 


30        PRACTICAL   EXAMINATION   OF   THE   URINE. 

quantity  of  solid  matters,  and  thence  that  of  water,  may  be 
readily  obtained  by  multiplying  the  last  two  figures  of  the 
sp.  gr.  by  what  is  known  as  Trapp's  coefficient — 2.33.  This 
will  give  approximately  the  number  of  the  grammes  in  the 
1000  c.c.  (33.8  f.oz.). 

Thus,  suppose  the  twenty -four  hours'  urine  to  be  1200  c.  c. 
and  the  sp.  gr.  to  be  1022,  then 

22  X  2.33  =  51.26  grms.  in  1000  c.  c. 

But  the  total  quantity  of  urine  in  twenty-four  hours  is 
1200  c.  c.,  therefore  it  will  contain  more  than  1000  c.  c.  con- 
tain. Hence, 

1000  :  1200  :  :  51.26  •  r  _51-26  X  1200_  R1  ^  grms_  (948i09  grs-) 
1000 

Now  the  normal  amount  of  solid  matters  in  the  twenty- 
four  hours  is  about  70  grammes  (1080.1  grs.),  showing  that 
in  this  instance  rather  less  than  the  normal  quantity  was 
separated.  In  this  manner  valuable  information  bearing 
upon  diagnosis  and  prognosis  may  be  obtained  in  a  few  se- 
conds. The  most  striking  variations  are  observed  in  diabetes 
and  Bright's  disease,  the  former  of  increase  in  solids  by 
addition  of  sugar,  the  latter  in  diminution  by  loss  of  urea. 

While  this  method  of  arriving  at  the  solids  is  not  suffi- 
ciently accurate  for  scientific  use,  it  answers  for  ordinary 
clinical  purposes. 


CONSTITUENTS.  31 


THE  STUDY  OF  THE  DIFFERENT  CONSTITUENTS  OF  URINE 
IN  HEALTH  AND  DISEASE. 

In  the  examination  of  a  specimen  of  urine,  the  following 
are  the  steps  which  will  be  found  most  convenient  in  actual 
practice.  Observe — 

I.  The  quantity  passed  in  twenty -four  hours. 
II.  Color  and  transparency. 

III.  Odor. 

IV.  Reaction. 

V.  Specific  gravity. 
VI.  Presence  or  absence  of  sediment,  its  quantity,  and 

characters. 

In  all  cases,  whether  the  sediment  be  appreciable  or 
not,  a  portion  of  the  fluid  should  be  set  aside  in  a  conical 
glass  vessel  for  twelve  hours,  with  a  view  to  collecting  the 
sediment  for  microscopical  examination.  The  remaining  or 
supernatant  fluid,  filtered  if  necessary,  should  then  be  fur- 
ther examined. 

Organic  Constituents. 

VII.  Presence  or  absence  of  albumen. 
VIII.  Presence  or  absence  of  sugar. 

fv    f\  \    •  ( Normal. 

IX.   Coloring  matters  \ 

(Abnormal. 

These  three  are  made  to  precede,  because  they  should 
form  a  part  of  every  examination. 

X.  The  biliary  acids. 

XI.  Leucin  and  tyrosin. 

XII.  Urea. 

XIII.  Uric  acid. 


32         PRACTICAL   EXAMINATION   OF   THE   URINE. 

Inorganic  Constituents. 
XIV.  Chlorides. 
XV.  Phosphates    ja'  Earthy  phosphates. 

(6.  Alkaline         " 
XVI.  Sulphates. 

Examination  of  Sediment  Microscopically  and  Chemically. 

I.  Unorganized  deposits,  including  crystals  and  amorphous 
deposits. 

II.  Organized  deposits,  including   anatomical   elements, 
such  as  casts,  epithelium,  pus,  blood-corpuscles,  etc. 

III.  Other  morphological  elements,  as  fungi,  pigmentary 
particles,  granular  matter,  extraneous  substances,  etc. 

Nos.  I,  II,  III,  IV,  V,  VI  require  no  further  explanation 
than  is  involved  in  the  consideration  of  the  "  general  physi- 
cal and  chemical  characters." 

Organic  Constituents. 

0 

VII.  To  DETECT  THE  PRESENCE  OF  ALBUMEN. 

In  all  instances  where  the  urine  used  for  testing  is  not  per- 
fectly clear,  it  should  be  filtered  before  applying  the  tests. 
This  may  be  done  in  a  few  minutes  by  means  of  filtering- 
paper  and  a  funnel. 

(a)  The  test  by  Heat A  test-tube  is  filled  to  £  to  ^  its 

depth  with  clear  urine,  to  which,  if  it  be  not  of  distinctly 
acid  reaction,  a  few  drops  of  acetic  acid  are  added,  and  the 
fluid  boiled  over  a  spirit-lamp.  If  an  opacity  result,  the 
slightest  degree  of  which  becomes  visible  in  a  clear  urine 
held  in  a  good  light,  it  is  due  either  to  albumen  or  earthy 
phosphates.  If  the  latter,  it  promptly  disappears  on  the  ad- 


ORGANIC   CONSTITUENTS.  33 

dition  of  a  few  drops  of  nitric  acid;  if  albumen,  it  is  perma- 
nent. If  further  confirmation  is  desired,  to  the  boiling  urine 
quickly  add  half  as  much  of  the  stronger  potash  solution  (7, 
p.  15),  when  the  albumen  is  dissolved,  and  the  earthy  phos- 
phates again  separate  in  flocculi. 

If  the  urine  has  not  been  filtered,  and  is  opaque  from  the 
presence  of  amorphous  urates,  the  first  effect  of  the  applica- 
tion of  heat  is  to  clear  up  the  fluid,  and  as  the  temperature 
is  increased,  the  albumen,  if  present,  is  precipitated. 

Acetic  acid  is  preferred  to  nitric  for  acidulating  the  urine, 
because  if  the  quantity  of  albumen  is  small  it  may  be  held  in 
solution  by  nitric  acid ;  but  if  the  precaution  be  observed  of 
adding  only  a  single  drop  or  two,  nitric  acid  answers  as  well. 

(b)  The  Nitric  Acid  test  is  best  applied  according  to  Heller's 
method.  Upon  a  convenient  quantity  of  pure,  colorless  nitric 
acid  in  a  small  test  tube  (one  of  those  with  a  foot,  seen  in 
Fig.  4,  is  most  suitable),  allow  to  trickle  from  a  pipette 
down  the  side  of  the  inclined  glass  an  equal  amount  of  clear 
urine,  which  will  thus  overlie  the  acid.  If  albumen  is  pre- 
sent, there  appears  at  the  point  of  contact,  between  the  urine 
and  nitric  acid,  a  sharp  white  band  or  zone  of  varying  thick- 
ness, according  to  the  quantity  of  albumen  present. 

The  urine  may  be  put  into  the  glass  first,  if  preferred,  and 
the  acid  may  then  be  allowed  to  pass  down  the  side  and 
under  the  urine.  The  result  is  the  same,  but  I  think  the 
former  is  somewhat  more  easily  practised. 

Precautions — 1.  Much  difficulty  is  often  experienced  in 
causing  the  urine  to  flow  from  the  pipette  sufficiently  slowly 
— that  is,  it  will  either  not  flow  at  all,  or  the  finger,  in  the 
effort  to  cause  it  to  flow,  is  suddenly  raised  so  much  as  to  per- 
mit a  sudden  flow  of  the  urine  into  the  acid,  which  interferes 
with  the  success  of  the  test.  This  difficulty  is  readily  over- 


34 


PRACTICAL   EXAMINATION    OF   THE    URINE. 


come  by  rotating  the  pipette  covered  by  the  end  of  the  index- 
finger,  between  the  middle  finger  and  the  thumb,  whereby 
the  flow  may  be  easily  controlled ;  the  process  is  further 
facilitated  if  the  upper  end  of  the  pipette  is  slightly  roughened. 


Fio.  4. 


Testing  for  albumen  by  nitric  acid. 

2.  A  somewhat  similar  white  zone  is  formed  by  the  action 
of  nitric  acid  on  the  mixed  urates  if  present  in  excess,  by 
which  the  more  insoluble  acid  urates  are  thrown  down.  This 
zone  might  be  mistaken  for  that  of  albumen ;  but  the  acid 
urates  begin  to  appear,  not  so  much  at  the  border  between 
the  urine  and  acid  as  higher  up;  nor  is  the  zone  on  the  upper 
surface  so  sharply  defined,  but  more  irregular,  or  in  "cloudy 
streaks."  By  Hoffmann  and  Ultzmann  the  appearance  is 


ORGANIC   CONSTITUENTS.  35 

compared  to  the  "cloudlike  curling  of  rising  smoke."  Fur- 
ther, this  layer  if  caused  by  urates  is  easily  dissipated  on  the 
application  of  heat,  although  some  care  is  necessary  in  this 
application  lest  in  ebullition  the  ring  be  commingled  with 
the  entire  mass  of  fluid  and  thus  lost  to  view,  although  not 
actually  dissolved.  After  some  hours  have  elapsed  these 
amorphous  acid  urates  are  completely  decomposed  by  a  fur- 
ther action  of  the  nitric  acid,  and  uric  acid  is  then  deposited 
as  a  characteristic  crystalline  sediment.  Further  difficulty 
arises  where,  as  is  occasionally  the  case  in  very  severe  cases 
of  fever,  a  small  quantity  of  albumen  coexists  with  an  excess 
of  acid  urates.  In  these  cases  the  urine  is  of  high  specific 
gravity,  and  the  line  of  albumen,  lying  immediately  on  the 
acid,  may  be  obscured  by  the  broader  band  and  cloud  of 
urates.  But  even  here,  if  the  method  laid  down  on  page  41 
is  carefully  followed  out,  a  mistake  is  scarcely  possible. 

It  should  be  added  that  Thudicum  considers  this  "cloud" 
of  acid  urates  here  referred  to,  to  be  not  urates  but  hydrate 
of  uric  acid.* 

3.  This  method  obviates  the  possibility  of  two  further 
sources  of  error  pointed  out  by  Bence  Jones :  first,  that,  if 
albuminous  urine  be  acidified  by  a  small  quantity  of  acid,  as 
a  drop  or  two,  no  precipitation  of  albumen  takes  place,  while 
if  too  large  a  quantity,  as  an  equal  bulk,  of  acid  be  added,  the 
mixture  in  like  manner  remains  perfectly  clear.  Roberts 
says  he  has  known  the  latter  fallacy  to  cause  the  concealment 
of  albumen  in  the  urine  for  months  in  a  case  of  Bright's  dis- 


4.  Occasionally,  also,  it  happens  that  a  urine  is  so  highly 
concentrated — so  highly  charged  with  urea — that  the  simple 

*  Thudicum,  J.  L.  W.,  Pathology  of  the  Urine,  2d  Ed.,  London, 
1877,  p.  377. 


36        PRACTICAL   EXAMINATION   OF   THE   URINE. 

addition  of  nitric  acid  causes  a  precipitation  of  crystals  of 
nitrate  of  urea.  But  these  are  readily  distinguished  from 
albumen  by  their  solubility  by  heat,  and  by  their  appearance 
under  the  microscope,  which  exhibits  them  made  up  of  six- 
sided  rhombic  tablets.  Such  urine  is  always  of  high  specific 
gravity,  while  albuminous  urine,  except  in  cases  of  acute 
Bright's  disease,  is  apt  to  be  of  low  specific  gravity. 

5.  If  carbonic  acid  be  abundantly  present  in  urine,  either 
free,  or  combined  with  ammonium  as  in  the  alkaline  ferment- 
ation, or  with  sodium  or  potash,  during  the  administration 
of  alkaline  carbonates  or  salts  of  the  vegetable  acids,  the 
addition  of  an  acid  liberates  it  with  effervescence.  Under 
ordinary  circumstances,  this  does  not  interfere  with  the  test ; 
but  if  the  quantity  of  carbonate  of  ammonium  be  very  large, 
as  is  the  case  in  some  old  urines,  and  the  quantity  of  albu- 
men small,  the  effervescence  is  so  great  as  to  make  the 
nitric  acid  test  impossible ;  while  the  amount  of  acetic  acid 
required  to  secure  an  acidity  sufficient  to  permit  the  use  of 
the  heat  test  may  be  so  great  as  to  completely  hold  in  solu- 
tion the  small  quantity  of  albumen.  Such  difficulty  is  fur- 
ther increased  by  the  fact  .that  these  alkaline  urines  are 
always  more  or  less  cloudy,  from  the  presence  of  amorphous 
phosphates  and  of  bacteria,  and  cannot  be  cleared  up  by 
ordinary  filtration.  Under  these  circumstances,  boil  the 
urine  with  a  fourth  part  of  its  volume  of  the  stronger  solution 
of  caustic  potash  (p.  15,  7),  and  filter.  If  the  filtrate  is  still 
not  quite  clear,  add  one  or  two  drops  of  the  magnesian  fluid  ; 
warm  again,  and  filter.  The  fluid  is  then  always  clear  and 
transparent,  and,  after  being  carefully  acidulated  with  acetic 
acid,  will  show  the  smallest  trace  of  albumen.  But  it  can 
be  made  even  more  apparent ;  if  to  the  fluid  acidulated  with 
acetic  acid,  a  few  drops  of  a  solution  of  yellow  prussiate  of 


ORGANIC   CONSTITUENTS.  37 

potash  be  added,  the  mixture  shaken  and  allowed  to  stand 
for  a  few  minutes,  white  flakes  of  separated  albumen  will 
soon  be  seen  at  the  bottom  (Hoffmann  and  Ultzmann). 

When  nitric  rtcid  is  thus  allowed  to  underlie  normal  urine, 
there  appears  between  the  urine  and  the  acid  a  brown  ring 
which  grows  in  intensity  on  standing,  and  is  due  to  the  action 
of  the  acid  on  the  coloring  matters.  In  consequence  of  this 
fact,  when  the  urine  is  highly  charged  with  coloring  matters, 
as  it  often  is  in  fever  cases,  the  albumen  precipitated  at  the 
same  place  is  similarly  tinted.  If  there  is  much  indican 
present  in  the  urine,  a  rose-red  or  violet  tint  may  be  com- 
municated to  the  albumen  ;  if  much  blood-coloring  matter,  a 
brownish-red,  and  if  undecomposed  biliary  coloring  matters, 
a  green  hue. 

Other  Tests  for  Albumen Nothing  is  said  of  the  numer- 
ous other  tests  for  albumen,  such  as  carbolic  acid,  picric 
acid,  corrosive  sublimate,  sulphate  of  copper,  alcohol,  etc., 
because  they  are  either  inapplicable,  or  less  accurate  than 
the  methods  described.  With  regard  to  M.  Gallipe's 
method,*  by  picric  acid,  however,  which  has  been  much 
lauded,  I  have  experimentally  determined  that  the  heat  and 
nitric  acid  tests  show  smaller  quantities  of  albumen  in  urine 
than  it  does,  while  my  friend,  Prof.  H.  P.  Bowditch  of 
Boston,  has  arrived  at  the  same  results,  by  experimenting 
with  carefully  prepared  solutions  of  egg  albumen  of  known 
strength,  t 

*  Brown-SSqnard's  Archives,  March,  1873,  p.  281 ;  and  Edin- 
burgh Monthly  Med.  Journal,  August,  1873. 

f  The  method  of  using  picric  acid  is  to  make  a  saturated  watery 
solution  (water  takes  np  a  very  small  quantity),  place  some  of  the 
solution  in  a  test-tube,  and  allow  the  urine  to  fall  into  it  drop  by 
drop,  when  each  drop  as  it  passes  through  the  solution  is  followed  by 

4 


38        PRACTICAL   EXAMINATION   OF   THE   URINE. 

Quantitative  Estimation  of  Albumen. 

It  is  a  matter  of  extreme  importance  in  the  course  of 
Bright's  disease  that  we  should  be  able  to  compare  the  quan- 
tity of  albumen  contained  in  the  urine  from  day  to  day.  The 
only  accurate  method  is  by  precipitation  by  acetic  acid  and 
boiling,  separation  by  filtration,  drying  and  weighing  by  deli- 
cately accurate  balances,  the  weight  of  the  filter  having  been 
previously  determined.  This,  however,  involves  too  much 
time  for  the  busy  practitioner,  and  we  must  fall  back  on  one 
of  the  approximative  methods.  The  best  known  of  these  is 
to  boil  a  given  quantity  of  urine  in  a  test-tube,  add  a  few 
drops  of  nitric  acid,  and  set  aside  for  at  least  twelve  hours. 
The  proportion  of  bulk  occupied* — one-fourth,  one-eighth,  a 
trace,  etc.,  is  used  to  indicate  the  quantity  of  albumen. 
Greater  accuracy  is  obtained  by  previously  filtering  the  urine 
of  urates,  epithelium,  or  extraneous  matter,  which  might 
unduly  increase  the  bulk  of  deposit  on  standing. 

More  definite  but  perhaps;  scarcely  more  accurate  is  the 
approximative  quantitative  estimation  by  means  of  Heller's 
nitric  acid  method  as  given  by  Hoffmann  and  JJltzmann. 
According  to  them,  if  the  white  zone  of  albumen  has  the 
depth  of  a  crow-quill,  is  delicate  and  faintly  white  in  color, 

an  opaque  white  cloud.  The  test  is  very  striking  and  beautiful, 
when  the  quantity  of  albumen  is  sufficient  to  permit  its  application. 
The  carbolic  acid  test  in  the  alcoholic  and  acetic  acid  mixture 
recommended  byMehu,  has  not  been  satisfactory  in  my  hands,  the 
milkiness  which  occurs  when  carbolic  acid  is  mixed  with  water  or 
non-albuminous  urine  obscuring  the  results.  With  the  mixture 
of  equal  parts  of  acetic  and  carbolic  acids,  recommended  in  the 
London  Medical  Times  and  Gazette,  of  September  26,  1874,  I  have 
had  no  experience. 


ORGANIC   CONSTITUENTS.  39 

has  no  granular  appearance,  and  appears  clearly  defined  only 
when  placed  against  a  dark  background,  the  quantity  is  less 
than  half  of  one  per  cent.  If,  however,  the  zone  of  albumen 
appears  granular  and  flocculent,  and  sinks  in  more  or  less 
lumpy  masses  to  the  bottom,  and  when  by  stirring  the  albu- 
men by  means  of  a  glass  rod  the  mixture  assumes  the  con- 
sistence and  appearance  of  sour  cream,  then  the  quantity  is 
very  large,  one  to  two  per  cent. 

Roberta's  Quantitative  Method  for  Albumen. 

Dr.  William  Roberts,  of  Manchester,  England,  suggests*  a 
method  for  clinical  purposes  which  consists  in  progressively 
diluting  the  urine,  and  testing  from  time  to  time  with  nitric 
acid  until  the  opacity  caused  by  the  acid,  becoming  fainter  and 
fainter,  finally  does  riot  appear.  This  point  is  reached  when 
the  urine  contains  less  than  about  0.0014  per  cent,  of  albumen. 
As  it  is  impossible  to  fix  the  vanishing  point  of  the  reaction 
with  accuracy,  Dr.  Roberts  draws  the  line  at  a  reaction  appear- 
ing midway  between  30  and  45  seconds  after  the  addition  of 
the  acid  ;  that  is,  he  dilutes  the  urine  until  it  gives  no  reaction 
for  30  seconds  after  the  contact  of  the  acid,  but  becomes  dis- 
tinctly*bpalescent  at  the  45th.  Each  dilution  by  a  volume  of 
water  equivalent  to  the  original  unit-volume  of  urine  employed, 
is  counted  1  degree  on  the  scale,  so  that  a  urine  requiring  40 
volumes  of  water  to  reach  the  0  reaction,  may  be  said  to  possess 
40  degrees  of  albumen.  Ascertaining  the  degrees  of  albumen 
by  the  dilution  method,  and  then  estimating  it  by  the  weigh- 
ing method,  each  degree  on  the  dilution  scale  was  found  to 
correspond  to  .0034  p.  c.  The  proportion  of  albumen  in  urine 
is  then  obtained  by  multiplying  the  degrees  of  albumen  by  the 
co-efficient  .0034.  Thus  a  urine  which  possesses  250  degrees 

*  American  Journal  of  the  Medical  Sciences,  January,  1878,  p. 
209  ;  from  the  Mudico-Chirurgical  Transactions,  vol.  xli.,  1876. 


40         PRACTICAL   EXAMINATION   OF   THE    URINE. 

of  albumen  contains  250  X  .0034  =  .85,  whence  it  is  easy  to 
calculate  from  the  24  hours'  urine  the  total  24  hours'  loss. 
Thus,  if  the  patient  pass  900  c.  c.  in  24  hours,  and  a  given 
quantity  shows  250  degrees  of  albumen,  or  .85  per  cent.,  then 
900  X  -85  =  765  centigrammes,  or  7.65  grms.  loss  in  24  hours. 
Dr.  Roberts  says  that  the  dilution  method  compares  favor- 
ably with  the  weighing  process,  even  in  urines  selected  for 
their  suitability  to  the  latter  ;  but  it  is  vastly  more  convenient 
and  brief,  and  is  more  generally  applicable  to  all  grades  of 
albuminous  urines. 

Remarks  on  Testing  for  Small  Quantities  of  Albumen, 
with  the  Author's  Method. 

To  determine  the  presence  of  albumen  in  urine  when  it  is 
abundantly  present,  is  a  very  simple  matter.  The  applica- 
tion of  heat  will  throw  down  albumen  even  from  an  alkaline 
solution  if  highly  charged  with  it,  while  the  addition  of  a  few 
drops  of  acid  removes  all  possibility  of  error.  But  it  is  well 
known  that  small  quantities  of  albumen,  the  significance  of 
which  in  diagnosis  and  prognosis  is  often  more  important 
than  that  of  large  amounts,  often  escape  detection ;  and  it  is 
with  a  view  to  pointing  out  the  way  to  avoid  such  errors 
that  the  following  paragraphs  are  introduced. 

Under  all  ordinary  circumstances  by  far  the  most  distinctive 
test  for  small  quantities  of  albumen  is  that  form  of  the  nitric 
acid  test  described  as  Heller's  (p.  33),  and  in  the  majority 
of  cases,  this  test,  carefully  carried  out,  even  in  the  hands 
of  the  inexperienced,  will  exhibit  the  presence  of  albumen 
when  it  would  have  been  overlooked  in  the  ordinary  mode 
of  application  of  the  heat  and  nitric  acid  test.  But  in  the 
course  of  an  experience  involving  almost  daily  examinations 
of  urine,  I  have  met  several  instances  in  which  it  failed  to 
give  satisfactory  evidence  of  the  presence  of  albumen,  when 


ORGANIC    CONSTITUENTS.  41 

the  ordinary  heat  and  acid  test,  applied  in  the  manner  to 
be  described,  proved  it  conclusively. 

Many,  who  have  often  tested  urine  for  albumen  by  the 
ordinary  heat  and  acid  test,  will  have  observed  that  after 
boiling  the  clear  urine  and  adding  a  few  drops  of  nitric  acid, 
the  resulting  fluid  will  be  apparently  clear ;  but  upon  setting 
aside  the  urine  thus  treated,  say  for  twelve  hours,  or  until 
the  next  morning,  there  will  sometimes  be  found  a  small 
deposit.  Supposing  the  urine  before  testing  to  have  been 
carefully  filtered,  this  deposit  is  either,  1st,  acid  urates  ;  2d, 
urid  acid  ;  3d,  nitrate  of  urea  ;  or  4th,  albumen.  The  first 
result  from  a  partial  decomposition  of  the  neutral  urates  by 
the  nitric  acid  added  ;  the  second  by  a  further  action  of  the 
acid  upon  the  acid  urates,  and  a  resulting  complete  separa- 
tion of  the  uric  acid  from  the  sodium,  potassium,  etc.,  with 
which  it  was  combined ;  the  third  is  found  only  when  the 
urine  happens  to  be  highly  concentrated  and  contains  an  un- . 
usual  proportion  of  urea.  The  second  and  third  have  well- 
known  forms  of  crystallization  by  which  they  can  be  easily 
recognized  under  the  microscope,  but  the  acid  urates  and 
albumen  are  both  amorphous  and  cannot  therefore  be  thus 
distinguished.  All,  however,  except  albumen,  disappear  on 
the  reapplication  of  heat.  In  all  instances,  therefore,  urine 
which  has  been  tried  by  heat  and  nitric  acid,  should  be  boiled 
again  after  cooling  and  standing  from  six  to  twelve  hours, 
and  if  the  sediment  is  not  dissolved  after  such  ebullition,  it 
is  albumen. 

The  Author's  Method My  own  method,  therefore,  of  ex- 
amining a  specimen  of  urine  for  albumen  is  invariably  as 
follows  : — 

I.  Unless  perfectly  clear  it  is  first  filtered,  and  if  not  ren- 
dered clear  by  filtration,  it  is  clarified  by  strong  alkalies,  or 
4* 


42         PRACTICAL   EXAMINATION    OF   THE    URINE. 

the  magnesian  fluid,  according  to  directions  on  page  36.  A 
portion  of  the  filtered  fluid  is  then  taken,  and,  if  not  acid,  it  is 
cautiously  acidulated,  and  then  boiled,  being  carefully  watched 
in  a  good  light  for  detection  of  the  least  diminution  of  trans- 
parency. A  drop  or  two  of  nitric  acid  are  then  added,  and  if  a 
turbidity  which  has  ensued  upon  the  action  of  the  heat  dis- 
appears, it  is  caused  by  phosphates  of  lime  and  magnesia, 
and  not  albumen.  If  any  degree  of  turbidity  remains  it  is 
caused  by  albumen,  and  the  test  may  end  here — although 
it  is  well  to  put  the  tube  aside,  in  order  that  the  albumen 
may  subside  and  be  approximately  estimated.  If,  however, 
there  is  the  least  doubt  about  the  presence  of  albumen,  the 
tube  must  be  set  away,  carefully  protected  from.dust,  for  six 
to  twelve  hours,  in  order  that  any  appreciable  sediment  may 
subside,  and  be  subsequently  again  tried  with  heat. 

II.  A  test-tube  is  now  filled  to  the  depth  of  half  an  inch 
with  colorless  nitric  acid.  About  as  much  urine  is  then 
allowed  to  fall  gently  upon  it  in  the  manner  described  on  page 
33,  and  the  point  of  junction  of  the  two  fluids  carefully  ex- 
amined for  the  white  line.  This  is  best  observed  by  holding 
the  tube  in  front  of  a  dark  ground,  furnished  by  a  book  or  pam- 
phlet, just  below  the  upper  edge  of  the  latter,  so  that  the  light 
may  fall  obliquely  upon  the  line  of  junction  of  the  two  fluids, 
while  at  the  same  time  it  is  seen  against  the  dark  ground. 

When  this  double  test  is  carefully  applied  as  above  de- 
scribed, it  is  scarcely  possible  to  err  with  regard  to  the 
presence  of  albumen.  Where  it  is  abundantly  present,  it  is, 
of  course,  unnecessary  to  use  either  the  modified  heat  and 
acid  test,  or  the  Heller's  test,  although  the  latter  is  always 
useful  in  that  it  affords  one  means  of  approximately  estimat- 
ing the  amount  of  albumen.* 

*  I  was,  for  a  time,  under  the  impression  that  the  precaution 
above  described  with  regard  to  the  heat  and  acid  test,  was  identical 


ORGANIC    CONSTITUENTS.  43 


VIII.  To  DETECT  THE  PRESENCE  OF  SUGAR,  C6H,9O8. 

Of  the  large  number  of  tests  extant  for  the  presence  of 
sugar,  only  those  will  be  given  which  have  borne  the  trial  of 

with  one  suggested  by  Dr.  C.  E.  Brown-S6quard,  in  the  first  number 
of  his  Archives  of  Scientific  and  Practical  Medicine  (1873),  but  on 
looking  up  the  matter  find  that  he  there  says  :  "  If  we  first  test  by 
heat  urine  containing  albumen  (after  having  ascertained  that  it  is 
naturally  acid),  we  may  not  find  the  least  precipitate  ;  and  if  we 
add  nitric  acid  to  it  after  it  has  boiled  and  become  somewhat  cold, 
we  may  yet  not  find  precipitation  of  albumen.  But  if  ive  boil  a  second 
time  that  now  acidified  urine,  the  solidification  of  albumen  quickly 
takes  place,  and  a  precipitate  soon  appears."  A  comparison  of  this 
with  the  above  test  will  show  the  difference.  Although  Brown- 
Sequard  says  "this  is  certainly  what  we  see  in  almost  all  cases," 
I  must  confess  never  having  witnessed  such  precipitate  under  the 
precise  circumstances  he  describes — that  is,  immediately  after  the 
second  boiling. 

While  on  the  subject,  it  may  be  well  to  add  what  he  further  says 
in  the  same  connection.  "  In  three  cases  in  which  the  microscope 
showed  tubular  casts  in  the  urine,  the  albumen  contained  by  this 
fluid  was  so  modified  by  the  heat  that  if  the  urine  (which  was  nat- 
urally acid)  was  boiled  .first,  the  addition  of  nitric  acid  in  small  or 
in  large  quantity  at  a  low  temperature  or  at  the  degree  of  boiling, 
produces  no  solidification  of  that  protein  substance.  But  when  I 
added  either  a  small  or  large  quantity  of  nitric  acid  to  the  fresh 
unboiled  urine  and  then  boiled  it,  the  ordinary  coagulation  took 
place,  and  after  some  time  of  rest,  the  ordinary  precipitate  ap- 
peared. It  is  evident,  therefore,  that  there  is  sometimes  in  the 
urine  a  kind  of  albumen  which  loses  its  coagulability  by  boiling." 

The  lesson  from  these  facts  is  that  it  would  seem  necessary  to 
apply  the  heat  and  acid  tests  both  ways,  that  is,  the  acid  should 
first  be  added  to  the  urine  and  the  mixture  then  boiled,  as  well  as 
that  the  urine  should  be  first  boiled  and  the  acid  then  added.  I 
believe,  however,  that,  if  the  method  above  described  is  carefully 
carried  out,  albumen  cannot  be  overlooked. 


44         PRACTICAL   EXAMINATION    OF   THE   URINE. 

experience,  and  it  is  suggested  that  for  practical  purposes 
the  student  should  select  some  one  of  these  and  accustom 
himself  to  its  use,  and  to  the  modifications  in  results  to  which 
all  are  more  or  less  subject.  I  am  confident  that  much  of 
the  difference  of  opinion  with  regard  to  the  reliability  of  the 
different  tests  is  due  to  the  fact,  that  those  claiming  it  have 
had  more  experience  with  the  particular  test  which  they 
recommend.  Thus,  in  Germany,  Moore's  test  is  evidently 
the  favorite  one,  while  in  my  own  hands,  the  old  Trornmer's 
test  gives  great  satisfaction,  simply,  perhaps,  because  I  have 
become  accustomed  to  its  use.  But  it  is  necessary  to  be 
familiar  writh  more  than  one  test,  because  cases  of  doubt  con- 
stantly arise  where  the  evidence  of  one  is  insufficient.  Al- 
though Briicke  has  shown  that  sugar  is  present  in  very 
minute  quantity  in  normal  urines,  yet  the  amount  is  so 
slight  as  to  escape  detection  by  the  ordinary  tests. 

Specific  Gravity  and  Quantity  as  a  Test.— The  specific 
gravity  alone,  when  1030  or  more,  affords  a  presumption  of 
the  presence  of  sugar,  and  if  at  the  same  time  the  urine  is 
very  pale,  and  far  exceeds  1500  c.  c.  (50  fl.  oz.)  in  twenty- 
four  hours,  the  probabilities  are  much  increased.  These 
facts  at  least  call  for  the  use  of  other  tests  to  determine  the 
question.  Further,  if  the  quantity  of  sugar  is  very  large,  a 
sweetish  odor  and  taste  is  communicated  to  the  urine.  (See 
case  referred  to  on  p.  24.) 

In  using  any  of  the  following  tests,  if  albumen  is  at  all 
abundantly  present,  it  should  jirst  be  removed  by  boiling  and 
filtration. 

Moore's  Test.—-M.oore's  test  depends  upon  the  fact  that 
grape-sugar,  with  which  diabetic  sugar  is  identical,  becomes 
oxidized  when  boiled  in  contact  with  caustic  alkali,  taking 
the  oxygen  from  the  atmosphere. 


ORGANIC    CONSTITUENTS.  45 

To  a  small  quantity  of  urine  in  a  test-tube,  add  half  as 
much  liquor  potassa  or  liquor  soda,  and  boil.  If  sugar  is 
present,  a  yellowish-brown  color  soon  makes  its  appearance, 
which  becomes  more  intense  as  the  boiling  is  continued,  and 
which  will  be  the  deeper  the  larger  the  proportion  of  sugar, 
becoming  finally  almost  black  if  the  quantity  is  very  large. 
The  coloration  is  due  to  the  formation,  first,  of  glucic,  and 
finally  of  melassic  acid,  both  of  which  remain  in  solution. 
The  flaky  precipitate  which  is  observed  after  the  addition  of 
the  alkali,  and  is  increased  on  the  application  of  heat,  is 
made  up  of  the  earthy  phosphates,  which  may  be  filtered  off 
before  the  heat  is  applied  if  very  abundant. 

If  now  to  the  colored  fluid  a  few  drops  of  nitric  acid  be 
added,  the  brown  coloration  disappears,  and  the  odor  of 
burnt  molasses  is  developed,  and  in  this  we  have  Heller's 
modification  of  Moore's  test. 

Precautions — 1.  Solutions  of  soda  and  potash  are  liable 
to  become  impregnated  with  lead,  either  from  being  kept  in 
flint-glass  bottles,  or  from  the  glazed  earthenware  vessels  in 
which,  during  preparation,  they  are  evaporated.  Such  con- 
tamination always  causes  the  production  of  a  brown  and 
black  color  when  boiled  with  organic  matter  containing  sul- 
phur, due  to  the  formation  of  sulphuret  of  lead.  This  error 
may  be  avoided  by  first  ascertaining  the  purity  of  the  alka- 
line solutions,  and  afterwards  keeping  them  in  green  glass 
bottles. 

2.  If  the  urine  exhibits  already  a  high  color,  which  is, 
however,  very  rare  with  diabetic  urines,  the  coloring  matters 
may  be  precipitated  by  solution  of  acetate  (sugar)  of  lead, 
which  does  not  at  all  interfere  with  the  sugar,  although  the 
sM^acetate  of  lead  throws  down  also  a  small  quantity  of 
sugar. 


46        PRACTICAL, EXAMINATION"   OF   THE   URINE. 

3.  The   coloring  matters  of  bile   in   urine,  either  when 
pure,  or  decomposed  (that  is,  when  they  respond  neither  to 
Grnelin's  nor  Heller's  test),  produce  a  brown  color  with  liquor 
potassa  or  soda  without  the  application  of  heat. 

4.  Bodeker  found  in   the   urine  of  an  adult  a  substance 
which   he   calls   alkctpton,  which  when   strong  solutions   of 
alkali  are  added  produces  a  brown  discoloration  from  above 
downward.     This,  according  to  him,  also  reduces  the  salts 
of  copper,  but  does  not  affect  the  bismuth  salts. 

The  Copper  Tests.  Trommer's  Test — The  copper  tests  de- 
pend upon  the  power  which  grape-sugar  possesses  of  reducing 
the  oxide  of  copper  in  common  with  other  metallic  oxides, 
as  silver,  gold,  etc.,  to  a  lower  state  of  oxidation.  In  Trom- 
mer's test,  the  oxide  of  copper  is  set  free  at  the  time  of  its 
application  by  liquor  potassae  or  soda  in  excess. 

1.  A  drop  or  two  of  a  (preferably  weak — say  1  to  30) 
solution  of  cupric  sulphate  is  added   to  the  suspected  urine, 
and  then  liquor  potassae  or  sodaa  equal  to  half  the  total  vol- 
ume.    On  first  adding  the  alkali  there  is  immediately  liber- 
ated, in  addition  to  the  earthy  phosphates,  a  blue  precipitate 
of  hydrated  cupric  protoxide,  tvhich,  if  sugar  is  present,  is 
redissolved  on  adding  more  alkali,  producing  a  beautiful  blue 
transparent  liquid.     If,  on  the  other  hand,  no  sugar  is  pre- 
sent, the  fluid  will  not  be  thus  blue  after  the  addition  of  the 
copper  and  alkali,  but  exhibit  rather  a  turbid  greenish  hue. 
This,  however,  is  not  alone  relied  upon,  but  the  mixture  is 
boiled,  and  if  sugar  is  present,  a  copious  yellow  precipitate 
of  hydrated  cupric  suboxide  takes  place.     This  subsequently 
loses  its  water  and  becomes  the  red  suboxide  which  falls  to 
the  bottom  or  sides  of  the  test-tube,  to  which  it  often  closely 
adheres. 

2.  A  second  similarly  prepared  mixture  of  these  ingre- 
dients should  be  made  and  set  aside  without  the  addition  of 


ORGANIC   CONSTITUENTS.  47 

heat  for  from  1  to  24  hours.  If  sugar  is  present  a  similar 
precipitate  of  suboxide  of  copper  will  take  place.  This  re- 
petition of  the  test  is  very  important,  since  Neubauer  says 
that  the  other  organic  substances  which  reduce  the  salts  of 
copper  do  so  only  after  long  boiling. 

Precautions 1.    Albumen,  if  present,   must  always  be 

removed,  as  it  interferes  with  the  reduction  of  the  copper. 

2.  Too  much  or  too  strong  a  solution  of  cupric  sulphate 
should  not  be  used,  lest  the  blue  color  of  the  unreduced  copper 
should  obscure  the  yellow  or  red  of  the  reduced. 

3.  While  the  fluid  must  be  made  to  boil  for  perhaps  half 
a  minute,  the  precipitate  should  take  place  without  prolonged 
boiling,  as  numerous  organic   substances  other  than  sugar 
will  reduce  the  salts  of  copper  by  prolonged  boiling. 

4.  The  flocculent  precipitate  of  earthy  phosphates  should 
not  be   mistaken  for  the  suboxide  of  copper ;  it  is  either 
transparent  or  of  a  pale  greenish  hue.     On  the  other  hand, 
a  mere  change  of  color  is  not  sufficient.     There  must  be  an 
actual  yellow  or  red  precipitate.     If  it  be  desired  to  elimi- 
nate this  source  of  error  altogether,  it  may  be  done  by  add- 
ing the  potash  solution,  and  filtering  before  adding  the  copper. 

5.  As  already  stated,  cupric   protoxide  is  sometimes  re- 
duced by  other  organic  matters  found  in  urine,  as  uric  acid, 
indican,  etc.     So  also  a  small  amount  of  sugar  may  even 
be  present  in  urine  and  fail  to  reduce  the  oxide  in  the  pre- 
sence of  certain  other  substances.     Dr.  Beale*  has  shown 
that  ammonium  chloride,  ammonium  urate,  and  other  ammo- 
niacal  compounds  have  this  latter  effect,  and  Neubauerf  tells 
us  that  creatinin  acts  similarly.    Recently  Dr.  George  Hay,} 

*  Kidney  Diseases  and  Urinary  Deposits,  p.  246. 
f  Analyse  des  Harris,  p.  76. 

J  Philadelphia  Medical  Times,   vol.  vii.,  1877,  p.  489,  and  vol. 
viii.,  1878,  p.  28. 


48        PRACTICAL   EXAMINATION   OF   THE   URINE. 

of  Pittsburg,  Pa.,  has  reaffirmed  both  of  these  sources  of 
error  with  such  force  as  to  throw  a  good  deal  of  discredit  on 
Trommer's  test.  While  I  have  long  been  in  the  habit  of 
using  this  test  very  frequently,  and  have  grown  to  rely  upon  it 
in  my  own  hands  as  second  to  none  except  the  fermentation 
test,  I  strongly  insist  upon  the  use  of  some  other  in  addition, 
wherever  there  is  the  least  doubt,  and  always  that  the  ele- 
ments of  Trommer's  test  shall  be  added  to  a  portion  of  the 
same  urine  and  allowed  to  stand  twenty-four  hours  without 
the  addition  of  heat.  This  is  less  troublesome  than  the  fer- 
mentation test,  the  elements  of  which  are  not  always  at  hand, 
although  it  occupies  as  much  time.  Attention  should  be  paid 
to  the  specific  gravity,  to  the  fact  that  a  precipitate  of  the 
phosphates  always  takes  place  which  must  not  be  mistaken 
for  the  suboxide,  and  that  the  disappearance  of  the  blue  color 
and  the  substitution  of  a  yellowish  tinge  is  also  not  to  be 
mistaken  for  a  precipitate.  This  yellowish  color,  however, 
is  apt  to  indicate  either  a  partial  reduction  by  some  other 
organic  substance,  or  by  the  sugar  itself,  and  demands  that 
the  urine  should  be  subjected  to  tlie  bismuth  or  fermentation 
test,  or  to  both. 

Other  Copper  Test  Solutions.  Fehling's  and  Pavy's 
Fluids — It  has  been  stated  that  when  an  alkali  is  added  to 
a  solution  of  sulphate  of  copper  an  abundant  precipitate  of 
hydrated  cupric  protoxide  is  thrown  down.  This  is  not 
dissolved  by  any  excess  of  alkali  added,  but  if  some  organic 
matter  is  added  or  happens  to  be  present,  an  excess  of  alkali 
dissolves  the  protoxide.  It  is  for  this  reason,  that  if  sugar 
happens  to  be  present  in  a  suspected  fluid  to  which  these 
have  been  added,  the  precipitated  protoxide  is  dissolved  and 
a  clear  blue  fluid  results. 


ORGANIC   CONSTITUENTS.  49 

These  facts  enable  us  to  construct  a  fluid  which  will  hold 
the  protoxide  of  copper  in  solution ;  but,  in  selecting  an  or- 
ganic substance,  one  must  be  chosen  which  will  not  reduce 
the  oxide  of  copper  as  does  sugar,  else  it  will  make  our  test 
inoperative.  Such  a  substance  is  tartaric  acid,  which  is 
usually  employed. 

Of  the  numerous  test  fluids  employed,  only  Fehling's,  and 
Dr.  Pavy's  modification  of  it,  are  given,  since  these  are  most 
convenient  in  practice,  and  serve  also  for  quantitative  esti- 
mation. The  one  or  the  other  may  be  used,  as  it  is  pre- 
ferred to  work  with  the  English  or  metric  system. 

Fehling's  Solution 34.639  grammes  (534.479  grains) 

pure  crystallized  sulphate  of  copper  are  dissolved  in  about 
200  grammes  (3086  grains)  distilled  water  ;  173  grammes 
(2669.39  grains)  chemically  pure  crystallized  neutral  tar- 
trate  of  soda  are  dissolved  in  500  to  600  grammes  (7715  to 
9258  grains)  solution  of  caustic  soda  of  specific  gravity  1.12, 
and  into  this  basic  solution,  the  copper  solution  is  poured,  a 
little  at  a  time.  The  clear  mixed  fluid  is  diluted  to  1  litre 
(2.1  pints). 

10  c.  c.  (162  minims)  of  this  solution  will  be  reduced  by 
.05  gramme,  or  50  milligrammes  (.7715  grain),  diabetic 
sugar.  If  the  copper  solution  is  to  be  kept  some  time,  it  is 
absolutely  essential  that  it  should  be  placed  in  smaller 
(40-80  grammes)  bottles,  sealed,  and  kept  in  the  cellar. 

Pavy's  Solution  consists  of — 

Cupric  sulphate     ....  320  grains. 

Neutral  potassic  tartrate         .         .  640  grains. 

Caustic  potash        .         .         .         .  1280  grains. 

Distilled  water       ....  20  fluidounces. 

The  solution  is  made  in  the  same  manner  as  Fehling's, 
and  100  minims  correspond  to  ^  grain  grape-sugar,  the  for- 
5 


50        PRACTICAL   EXAMINATION   OF   THE   URINE. 

mula  for  grape-sugar  being  here  taken  C6H14O7,  while  by 
Fehling  it  is  taken  C6HlaO8.* 

These  solutions  serve  equally  well  for  qualitative  and 
volumetric  testing,  but  if  it  is  simply  desired  to  have  a  solu- 
tion for  the  former  purpose,  it  may  be  made  by  pounding 
together  5  grains  (.324  gramme)  cupric  sulphate,  10  grains 
(.648  gramme)  neutral  potassic  tartrate,  and  dissolving  in 
2  drachms  (7.4  c.  c.)  liquor  potassae.  The  usual  blue  fluid 
results. 

To  Use — In  using  either  of  the  above  solutions  for  quali- 
tative testing,  a  small  quantity  should  be  placed  in  a  test- 
tube  and  boiled  alone  for  a  few  seconds.  If  the  solution  re- 
mains clear  on  thus  boiling,  add  immediately  the  suspected 
urine  drop  by  drop.  If  sugar  is  present  in  any  quantity,  the 
first  few  drops  will  usually  cause  the  yellow  precipitate,  but 
the  dropping  may  be  continued  until  an  equal  volume  of  the 
urine  has  been  added,  when  the  mixture  is  again  boiled.  If 
no  precipitate  occurs,  sugar  is  absent. 

If  a  precipitate  occurs  on  boiling  the  test  fluid  alone,  a 
new  supply  may  be  obtained,  or  a  little  more  soda  or  potash 
may  be  added,  the  fluid  filtered,  and  it  is  again  ready  for 
use.  The  precipitate  referred  to  is  a  suboxide  of  copper,  the 
result  of  a  spontaneous  reduction  of  the  protoxide  which 
sometimes  occurs  when  Fehling's  or  Pavy's  solutions  are 
kept  for  some  time.  Boiling  causes  its  precipitation,  and 
hence  the  necessity  of  boiling  a  solution  which  has  been  kept 
for  any  length  of  time,  before  adding  the  suspected  fluid. 
All  possibility  of  such  source  of  error  may  be  avoided  by 
keeping  the  solution  of  copper  separate  from  that  of  the 

*  This  should  be  remembered,  as,  in  consequence  of  it,  the  same 
urine  in  the  hands  of  different  observers  would  yield  slightly  dif- 
ferent results,  according  as  one  or  the  other  solution  is  used. 


ORGANIC   CONSTITUENTS.  51 

potash  and  potassic  tartrate,  and  mixing  them  at  the  moment 
they  are  required  for  use. 

The  same  precautions  laid  down  with  regard  to  Trommer's 
test  are  here  to  be  observed. 

To  obviate  the  uncertainty  of  Trommer's  tests  and  the 
inconvenience  of  Fehling's,  Dr.  H.  G.  Piffard*  has  suggested 
the  following — 

New  Test  for  Sugar. 

Take  of— 

Sulphate  of  copper  (chemically  pure),  1  part. 
Crystallized  tartrate  of  soda  and  potassa,  5  parts. 
Sodic  hydrate  (chemically  pure),  2  parts. 

Mix  thoroughly  in  a  mortar. 

The  result  will  be  a  pasty  mass,  which  can  be  transferred 
to  a  wide-mouthed  bottle,  and  kept  till  wanted  To  use  it, 
take  of  the  mass  a  piece  about  the  size  of  a  small  pea,  put  it 
in  a  test  tube,  and  add  about  two  fluidrachms  of  water,  boil 
till  the  mass  is  dissolved,  and  the  solution  has  a  uniform, 
pale,  and  rather  dirty  blue  color ;  then  add  two  or  three 
drops  of  the  suspected  urine,  and  boil  again  for  a  moment. 
If  sugar  be  present,  the  usual  reaction  will  be  manifest. 

Bcetger's  Bismuth  Test  consists  in  adding  to  urine  in 
a  test-tube  an  equal  volume  of  liquor  potassae  or  sodae,  then 
a  pinch  of  the  ordinary  subnitrate  of  bismuth,  shaking  and 
boiling  for  a  couple  of  minutes.  The  sugar  possesses  the 
power  of  reducing  the  salts  of  bismuth,  and,  if  sugar  is  pre- 
sent, the  black  metallic  bismuth  will  shortly  be  deposited  on 
the  side  of  the  test-tube.  If  the  quantity  of  sugar  is  small, 
the  bismuth  will  assume  a  grayish  hue  ;  hence,  when  this  is 
the  case,  a  very  small  amount  of  bismuth  should  be  used  in 
making  the  test. 

*  New  York  Medical  Record,  March  23,  1878. 


52 


PRACTICAL   EXAMINATION    OF   THE    URINE. 


This  is  an  excellent  test,  and  the  one  I  usually  employ  to 
confirm  the  results  of  the  copper  test.  With  the  exception 
named  below,  no  other  substance  than  sugar  is  supposed  to 
reduce  bismuth  salts. 

Brucke's  Modification  of  the  Bismuth  Test.* — Professor 
Briicke  finds,  that,  while  Boetger's  bismuth  test  has  many 
advantages  over  Trommer's  test,  it  may  lead  under  certain 
conditions  to  false  results,  since  sulphur  occasionally  pre- 
sent in  the  urine  will  cause  the  same  reaction  as  glucose  ; 
hence  he  recommends  that  the  urine,  if  it  contain  a  sulphur 
compound,  be  faintly  acidulated  with  hydrochloric  acid,  then 
treated  with  a  solution  of  iodide  of  bismuth  and  potassium, 
which  completely  removes  the  sulphur,  while  it  does  not  affect 
the  glucose  in  the  slightest.  After  a  few  minutes  the  solu- 
tion is  filtered,  and  boiled  for  a  few  minutes  with  an  excess 
of  a  concentrated  solution  of  caustic 
potash  ;  if  the  solution  is  now 
colored  gray  or  black,  or  such  a  pre- 
cipitate is  formed,  the  presence  of 
sugar  is  proven  beyond  a  doubt. 

Precaution. — For  the  same  reason 
all  albumen  must  be  removed  from 
the  urine  to  be  tested  by  bismuth, 
since  it  affords  a  source  for  sulphur, 
which  in  like  manner  will  precipi- 
tate the  sulphide  of  bismuth. 

The  Fermentation  Test.  —  The 
most  reliable  of  all  tests  for  the  pres- 
ence of  sugar  is  the  fermentation 

test,  but,  being  somewhat  troublesome,  it  is  less  suitable  for 
the  practitioner  as  an  everyday  test.     The  most  convenient 

*  Proceedings  of  American  Pharmaceutical  Assoc.,  1877,  p.  287. 


Fio.  5.     (After  Barley.) 
b 


ORGAXIC    CONSTITUENTS.  53 

method  of  its  application  is  as  follows  :  A  test-tube  of  large 
size  is  provided  with  a  tightly  fitting  perforated  cork,  through 
which  one  limb  of  a  bent  glass-tube  long  enough  to  reach 
nearly  to  the  bottom  is  passed.  A  small  quantity  of  ordi- 
nary baker's  or  brewer's  yeast  (about  afluidrachm,  or  3  to  4 
c.  c.)  is  placed  in  the  tube,  which  is  then  filled  with  urine, 
tightly  corked,  allowing  no  air  to  remain,  and  placed  in  a 
vessel  which  may  be  filled  with  tepid  water,  in  a  room  at 
a  temperature  of  15-25°  C.  (59-77°  F.).  If  sugar  is  pre- 
sent, evidences  of  fermentation  will  present  themselves 
generally  within  twelve  hours  in  the  formation  of  carbonic 
acid,  which  will  force  the  fluid  out  of  the  bent  tube  into  the 
glass  vessel  arranged  for  its  reception.  If  carefully  per- 
formed, this  test  is  thoroughly  reliable. 

Quantitative  Estimation  of  Sugar. 

So  important  is  a  knowledge  of  the  daily  change  in  the 
quantity  of  sugar  in  the  urine  of  a  case  of  diabetes,  that  it 
may  be  laid  down  that  some  kind  of  quantitative  estimation 
from  day  to  day  is  absolutely  necessary. 

1.  Approximative  Estimation. — While  the  specific  gravity 
determined  from  the  twenty-four  hours'  urine  may  serve  to 
give  a  general  idea  of  the  increase  or  diminution  of  the 
amount  of  sugar,  in  consequence  of  the  complex  composition 
of  the  urine  it  cannot  be  relied  upon  even  for  approximate 
estimation,  as  it  might  be  in  a  simple  watery  solution  of  sugar. 

(a)  To  those  who  habituate  themselves  to  Moore's  test, 
the  method  of  Vogel  recommends  itself  by  its  simplicity  and 
brevity.  As  the  result  of  trial,  Vogel  has  determined  that 
solutions  of  grape-sugar,  when  boiled  with  half  their  bulk  of 
liquor  potassoe,  exhibit  the  following  changes  of  color :  A  1 
5* 


54         PRACTICAL   EXAMINATION    OF   THE    URINE. 

per  cent,  solution  becomes  canary  yellow;  a  2  per  cent,  a 
dark  amber ;  a  5  per  cent,  a,  dark  Jamaica  rum  (?)  ;  and  a 
10  per  cent,  a  dark  black-brown,  and  opaque,  while  all  solu- 
tions of  a  less  percentage  are  more  or  less  transparent. 

With  a  pale  urine,  in  the  hands  of  one  accustomed  to  this 
test,  if  the  specific  gravity  be  also  regarded,  tolerable  accu- 
racy may  be  obtained.  It  should  certainly  be  employed 
rather  than  none  at  all. 

(b)  Roberts's  Fermentation  Test  is  based  on  the  fact  that 
diabetic  urine  loses  in  specific  gravity  after  fermentation  is 
completed.  Dr.  Roberts  has  shown  by  careful  experiments 
that  every  "degree"  in  specific  gravity  lost  in  fermentation 
corresponds  to  one  grain  of  sugar  per  fluidotmce.  Thus,  if 
before  fermentation  the  specific  gravity  of  a  given  specimen 
is  1050,  and  after  fermentation  it  is  1020,  it  will  have  con- 
tained 30  grains  to  the  fluidounce.  The  method  recom- 
mended by  Dr.  Roberts  is  as  follows  :  Four  ounces  of  the 
saccharine  urine  are  put  in  a  12-ounce  bottle,  and  a  lump 
of  German  yeast,*  as  large  as  a  small  walnut,  is  added.  The 
bottle  is  then  covered  with  a  nicked  cork  to  permit  the  es- 
cape of  the  carbonic  acid,  and  set  aside  on  a  mantelpiece  or 
other  warm  place.  Beside  it  is  placed  a  tightly  corked  4- 
ounce  vial,  filled  with  the  same  urine,  but  without  any  yeast. 
In  eighteen  to  twenty-four  hours  fermentation  will  be  com- 
plete, and  the  scum  cleared  off  or  subsided.  The  specific 
gravity  of  the  decanted  fermented  urine  is  then  taken  ;  at 
the  same  time,  that  of  the  unfermented  urine,  and  a  com- 
parison made.  While  some  time  is  here  required  to  complete 
the  fermentation,  yet,  as  Dr.  Roberts  says,  the  preparations 
can  be  made  by  the  patient  himself  or  friends,  and  each  day, 

*  The  so-called  Vienna  yeast,  now  well  known  in  this  country, 
is  the  same  thing.  But  the  ordinary  liquid  yeast  answers  as  well. 


ORGANIC    CONSTITUENTS.  55 

when  the  .physician  makes  his  visit,  he  has  only  to  make  the 
comparison. 

2.  Volumetric  Process — The  exact  quantitative  methods 
are  those  by  Fehling's  or  Pavy's  solutions.  That  recom- 
mended hy  Pavy  is  by  far  the  most  convenient  in  practice, 
requiring  a  hundred-minim  graduated  pipette,*  a  measuring 
glass,  spirit-lamp  and  stand,  and  porcelain  capsule. 

In  an  ordinary  case  of  diabetes,  the  urine  contains  too 
much  sugar  to  be  tried,  unless  diluted  with  a  known  quantity 
of  wrater.  Generally  it  suffices  to  dilute  it  with  two  to  four 
times  its  bulk  of  water,  according  to  the  amount  of  sugar 
suggested  by  the  specific  gravity. 

One  hundred  minims  of  Pavy's  solution  (p.  49),  equiva- 
lent to  half  a  grain  of  sugar,  are  now  measured  out  into  a 
porcelain  capsule.  Into  this  a  fragment  of  caustic  potash, 
about  twice  the  size  of  a  pea,  is  dropped,  for  the  purpose  of 
causing  the  reduced  oxide  to  fall  in  a  denser  form,  so  that 
the  liquid  may  remain  clear,  and  allow  the  change  of  color 
to  be  more  readily  seen.  The  capsule  is  then  placed  over 
the  flame  of  a  spirit-lamp  or  gas,  on  a  retort  stand,  or  better, 
on  a  piece  of  iron  gauze,  adapted  to  the  top  of  a  stoneware 
cylinder,  as  arranged  in  the  cut,  Fig.  6.  The  cylinder  pro- 
tects the  flame  from  draught,  and  the  gauze  distributes  and 
regulates  the  heat. 

The  one-hundred-minim  pipette  is  now  filled  with  the 
mixture  of  urine  and  water,  and,  as  soon  as  the  fluid  in  the 
capsule  begins  to  boil,  the  contents  of  the  pipette  are  allowed 
to  fall  drop  by  drop  into  the  test  solution  in  the  capsule, 

*  For  some  time  it  was  impossible  for  me  to  get  a  minim  pipette 
in  this  city.  Finally  I  found  they  were  to  be  had  of  W.  H.  Pile, 
northwest  corner  of  Passyunk  Avenue  and  Catharine  Street,  who 
prepares  them  with  great  care. 


56         PRACTICAL   EXAMINATION   OF   THE   URINE. 

which  must  be  kept  boiling,  and  moved  about  by  tilting  with 
a  glass  rod,  until  all  the  blue  color  is  gone.  All  trace  of 
blue  should  be  removed,  and  a  little  experience  will  enable 
even  the  beginner  to  note  the  exact  point.  If  the  deposit 

FIG.  6.     (From  Tavy.) 


falls  slowly,  the  process  may  be  stopped  for  a  few  minutes 
until  it  has  subsided,  when  by  tilting  the  capsule  a  thin 
layer  of  the  fluid  may  be  examined  over  the  pure  white  por- 
celain, and  thus  any  remaining  coloration  detected.  We 
then  note  how  many  minims  of  the  urine  mixture  have  been 
used  to  decolorize  the  one  hundred  minims  of  test  solution, 
thence  the  number  of  minims  of  pure  urine,  and  thence  the 
quantity  in  the  whole  twenty -four  hours. 

Thus,  suppose  the  quantity  of  urine  in  twenty-four  hours 
to  be  100  ounces,  some  of  which  was  diluted  four  times — 
that  is,  of  100  minims  of  the  mixture  20  were  urine ;  sup- 


ORGANIC   CONSTITUENTS.  57 

pose,  further,  that  80  minims  of  this  mixture  exactly  reduced 
the  100  minims  of  solution  representing  the  half  grain  of 
sugar.  Then  one-fifth  only  being  urine,  we  have  learned 
that  16  minims  of  urine  contain  half  a  grain  of  sugar,  and 
from  this  that  an  ounce  contains  15  grains,  and  100  ounces, 
or  the  twenty-four  hours'  urine,  15  x  100  =  1500  grains. 

Fehling's  solution  may  be  used  in  precisely  the  same 
manner,  using,  however,  the  metric  system  of  measurement 
and  operation,  and  obtaining  results  in  the  same  system. 
Either  solution  may  be  dropped  from  a  burette  in  a  manner 
to  be  described  in  the  volumetric  analysis  for  urea,  etc. 


IX.    COLORING  MATTERS. 

The  pathological  significance  of  all  the  coloring  matters 
has  not  as  yet  been  determined.  Many  of  them  are,  how- 
ever, of  such  importance  that  their  consideration  commands 
interest  next  to  that  of  albumen  and  sugar. 

I.  Normal  Coloring  Matters Notwithstanding  the  very 

considerable  attention  which  has  been  given  to  this  subject 
x)f  late  years,  there  is  still  some  confusion  as  regards  the 
normal  coloring  matters.  Thus,  perhaps  most  recently, 
Hoffmann  and  Ultzmann,*  describing  Scherer's  method  of 
obtaining  his  urohaematin,  state  that  it  does  not  contain 
iron,  while  the  urohfematin  of  Harley  and  the  urophain  of 
Heller  do.  Further,  they  make  the  urohcematin  of  Harley 
identical  with  the  uroerythrin  of  Heller,  an  abnormal  color- 
ing matter.  Thudicumf  makes  a  single  coloring  matter 

*  Anleitung  zur  Untersuchung  des  Hams,  etc.     Wien,  1871. 
f  Thudicum,  A  Treatise  on  the  Pathology  of  the  Urine,  2d  Edi- 
tion, London, 1877. 


58        PRACTICAL   EXAMINATION  •  OF   THE   URINE. 

which  he  calls  urochrome,  in  the  composition  of  which  he 
does  not  appear  to  admit  iron. 

The  fact  is,  that,  while  it  is  probable  that  the  true  coloring 
matter  of  the  urine  has  not  been  precisely  determined,  the 
urohaematin  of  Scherer  and  Harley  are  identical,  Scherer* 
admitting  that  urohaematin  contains  iron,  and  approving  of 
the  use  of  the  term  by  Harley  for  his  coloring  matter.  The 
urophain  of  Heller  is  doubtless  practically  the  same  thing. 
It  will  at  any  rate  here  be  so  considered.  So  would  seem  to 
be  the  urochrome  of  Thudicum.  Upon  the  presence  of  in- 
dican  (Heller's  uroxanthin)  in  most  normal  urines,  all  are 
agreed,  although  Thudicum  prefers  not  to  consider  it  a 
coloring  matter,  but  a  chromogen  or  color  generator.  For 
the  present  I  shall  retain  it  among  the  normal  coloring 
matters,  making  therefore  two,  viz. : — 

1.  Urohaematin     (Harley    and     Scherer)     or    urophain 
'Heller)  ;  urochrome  (Thudicum). 

2.  Indican  or  the  uroxanthin  of  Heller. 


1.    Urophain —  Urohaematin —  Urochrome. 

Heller's  test  for  urophain  is  as  follows :  About  2  c.  c. 
(32.4  minims)  of  colorless  sulphuric  acid  are  poured  into  a 
small  beaker-glass,  or  better  a  "collamore"  wineglass  (p.  16), 
and  upon  it  in  a  fine  stream  from  a  height  of  about  four  inches, 
two  parts  of  urine  are  allowed  to  fall.  The  urine  mingles 
itself  intimately  with  the  sulphuric  acid,  and  in  normal  urine, 
of  which  the  specific  gravity  is  1020  and  the  quantity  1500 
c.  c.  in  the  twenty-four  hours,  produces  a  deep  garnet-red 
coloration. 

*  Harley,  The  Urine  and  its  Derangements,  Philadelphia,  1872, 
from  London  Edition,  1871. 


ORGANIC   CONSTITUENTS.  59 

If  the  coloring  matter  is  increased,  the  coloration  is  no 
longer  garnet-red,  but  is  black  and  opaque  ;  whereas,  if  the 
coloring  matter  is  diminished,  the  mixture  appears  pale 
garnet-red  and  transparent. 

Precautions — Unfortunately,  other  conditions  than  that 
of  increased  amount  of  coloring  matter  produce  the  increased 
intensity  of  the  urophain-reaction.  Thus  diabetic  urine  pro- 
duces the  same  dark  opacity  through  carbonization  of  the 
sugar  by  the  sulphuric  acid.  In  like  manner,  urine  contain- 
ing blood,  biliary  coloring  matters,  and  uroerythrin  (an 
abnormal  coloring  matter),  gives  the  same  reaction  with  sul- 
phuric acid.  Before  relying,  therefore,  upon  this  reaction, 
the  above  substances  must  be  carefully  excluded. 

Dr.  Harley's  test  for  urohtematin  is  as  follows  :  Dilute  the 
twenty-four  hours'  urine  with  water  till  it  measures  60 
ounces  (1800  c.  c.),  or,  if  the  quantity  exceeds  60  ounces, 
concentrate  it  to  this  amount ;  then  add  to  about  2  drachms 
(7.4  c.  c.)  of  it,  in  a  test-tube,  half  a  drachm  (1.8  c.  c.)  of 
pure  nitric  acid,  and  allow  the  mixture  to  stand  for  some 
minutes.  If  the  quantity  of  urohaematin  is  normal,  the 
mixture  will  alter  but  slightly  in  tint ;  whereas,  if  there  be 
an  excess,  it  will  become  pink,  red,  crimson,  or  purple  ac- 
cording to  the  amount  present.  Heating  the  mixture  hastens 
the  change  in  color,  but  it  is  better  to  do  this  experiment  in 
the  cold,  and,  if  necessary,  allow  plenty  of  time  for  the 
change  to  take  place. 

The  acid  is  added  to  liberate  the  coloring  matter,  which 
may  be  so  thoroughly  concealed  that  a  pale  urine  often  con- 
tains a  large  amount  of  urohcematin. 

He  gives  a  second  method,  also  easy  of  application,  of 
determining  its  excess  in  cases  of  destructive  diseases  of  the 
blood.  Boil  4  ounces  (120  c.  c.)  of  urine,  and  add  nitric 


60         PRACTICAL   EXAMINATION   OF   THE   URINE. 

acid  to  set  the  coloring  matter  free.  When  cool,  put  the 
urine  in  a  six-ounce  bottle  along  with  an  ounce  of  ether. 
Cork  the  bottle,  thoroughly  shake  it.  and  place  aside  for 
twenty-four  hours.  At  the  end  of  that  time  the  ether  will 
be  found  to  be  like  a  red,  tremulous  jelly.  Such  a  case, 
however,  he  admits  to  be  a  bad  one.  He  further  says,  that 
"  in  some  of  the  worst  cases  of  urohtematuria  the  urine  is 
neutral,  or  even  alkaline,  and  the  fans  et  origo  mail  is  to 
be  looked  for  in  the  spinal  cord." 

Dr.  Harley,  apparently  with  good  reason,  considers  that 
urohaematin  arises  from  the  disintegration  of  the  red  blood- 
corpuscles,  and  that  it  fluctuates^  therefore,  with  the  rate  of 
destruction  of  these. 

Urochrome  of  Thudicum — Thudicum  terms  the  substance, 
to  which  he  considers  the  whole  or  greater  part  of  the  yellow 
color  of  the  urine  is  due,  urochrome.  It  is  an  alkaloid,  but 
not  of  pronounced  basic  properties.  It  has  been  isolated,  but 
not  finally  analyzed.  Its  principal  characteristic  is,  that  on 
chemolysis  with  acids  it  is  split  up  into  several  bodies  of 
smaller  atomic  weight,  one  of  which — uromelanine — seems 
to  be  derived  from  the  coloring  ingredient  of  the  blood. 
Urochrome  does  not  show  any  specific  absorption  band  before 
the  spectroscope  when  strongly  acidified,  but  by  chemolysis 
probably  gives  rise  to  two  or  three  substances  having  distinct 
spectral  phenomena  which  greatly  aid  in  their  diagnosis.  It 
is  not  the  chromogen  of  urobilin. 

Thudicum  gives  (op.  citat.)  several  methods  of  isolating 
urochrome,  the  briefest  of  which  consists  in  precipitating 
fresh  urine  with  neutral  and  basic  lead  acetate,  decomposing 
the  precipitate  with  sulphuric  acid,  and  precipitating  the 
urochrome  (and  some  xanthine-like  body)  from  the  filtrate 
by  phosphomolybdic  acid. 


ORGANIC    CONSTITUENTS.  61 

Clinical  Significance  of  the  Increased   Urohcematin  or 
Urophain  Reaction. 

An  increase  of  the  urophain  (urohsematin)  reaction  has 
been  observed  under  the  following  circumstances. 

1.  In  concentrated  urines. 

2.  In  fever  urines. 

3.  In  the  urine  of  icterus  and  in  chronic  diseases  of  the 
liver.     In  the  latter,  and  biliary  obstructions,  an  increase  of 
the  urophain  reaction  may  show  itself,  even  when  Gmelin's 
or  Heller's  test  for  the  coloring  matters  of  bile  does  not  re- 
spond ;  since  the  products  of  their  decomposition  may  be 
present  when  the  proper  biliary  coloring  matters  themselves, 
bilirubin  and  bilifuscin,  are  wanting. 

4.  In  diabetic  urine  containing  abundant  sugar. 

5.  In  urine  rich  in  the  coloring  matters  of  blood. 

6.  A  large  amount  of  indican  in  the  urine  may  also  give 
a  strong  urophain  reaction.     So  marked  an  increase  in  indi- 
can alone  very  seldom  occurs,  but  it  often  happens  that  the 
blue  color  is  recognized  at  the  first  moment  of  the  test,  and 
gradually  passes  over  into  the  black  ;  but  by  dilution  with 
water  the  blue  may  again  be  made  to  appear.     Hofmann 
and  Ultzmann. 

2.  Indican  ;    Uroxanthin  of  Heller ;  Indigogen  of 
Thudicum 

Indican  or  uroxanthin  itself  is  a  colorless  substance  as  is 
indigo  at  first,  separable  from  urine  in  the  shape  of  a  clear 
brown  syrup  easily  soluble  in  water,  alcohol,  and  ether.  It 
has  a  bitter  taste,  and  is  easily  converted  by  treatment  with 
acids  under  warmth  into  indigo-blue  (the  uroglaucin  of 
6 


62         PRACTICAL   EXAMINATION   OF   THE   URINE. 

Heller),  a  red  coloring  matter  (urrhodin  of  Heller),  said  by 
Kletzinsky  to  be  identical  with  indigo-red,  but  denied  by 
Thudicum,  and  indigo-ghici?i,  a  saccharine  substance  which 
is  said  to  respond  to  Trommer's  test,  but  not  to  the  fermen- 
tation test.  According  to  Thudicum,  urrhodin  is  the  result 
of  chemolysis  by  acids,  of  a  separate  chromogen  which  he 
calls  urrhodinogen. 

Heller's  Test  for  Indican  is  performed  as  follows  :  3  or  4 
c.  c.  (48.6  to  64.8  minims)  of  pure  hydrochloric  acid  are 
poured  into  a  smooth  wine-  or  a  small  beaker-glass,  and  into 
the  same  while  stirring  10  to  20  drops  of  urine  are  dropped. 
Under  normal  conditions  indican  is  present  in  urine  in  so 
small  quantity  that  the  acid  to  which  the  urine  is  added  is 
colored  pale  yellowish-red.  If  indican  is  present  in  larger 
quantities,  the  coloration  is  violet  or  Hue.  The  more  abund- 
ant the  indican  the  more  rapid  does  the  violet  or  blue 
discoloration  take  place,  and  often  1-2  drops  of  urine  are 
sufficient  to  color  4  c.  c.  (64.8  minims)  hydrochloric  acid. 
The  blue  color  does  not  always  make  its  appearance  imme- 
diately. It  is  well  then  to  wait  10  or  15  minutes.  If  it  is 
desired  to  test  urine  containing  the  biliary  coloring  matters 
for  indican,  the  former  must  be  precipitated  by  solution  of 
acetate  (sugar)  of  lead,  and  filtered  out. 

Dr.  Harley  believes  that  all  the  various  colored  urine  pig- 
ments are  but  different  grades  of  oxidation  of  uroha;matin,  * 
and  thus  accounts  for  the  various  cases  of  blue,  green,  brown, 
and  black  urines  which  have  been  at  different  times  reported, 
a  most  important  fact  with  regard  to  which  is  that  they 
never  exhibit  these  colors  at  the  moment  the  urine  is  passed, 
but  acquire  them  after  exposure  to  the  air  or  the  action  of 
chemical  reagents.  He  believes  these  changes  which  occur 

*  Op.  citat,,  p.  110. 


OKGANIC   CONSTITUENTS.  63 

in  urohaunatin  out  of  the  body  are  primarily  due  to  its  con- 
stitution in  the  body  having  been  altered  by  disease. 

lie  admits,  however,  in  common  with  others,  that  some 
portion  of  the  coloring  matter  of  the  urine  comes  from  the 
food,  chiefly  vegetable  food.* 

Senator's  Method  for  Indican^  is  more  striking  in  its  re- 
sults, and  is  even  approximately  quantitative.  To  10  or  15 
c.  c.  (2.7  or  3.24  f3)  of  urine  in  a  large  test  tube  add  an 
equal  amount  of  hydrochloric  acid,  and  then,  with  constant 
shaking,  a  saturated  solution  of  calcic  hypochlorite  (chloride 
of  lime)  drop  by  drop,  until  the  greatest  intensity  of  the 
blue  color  is  reached.  This  is  then  shaken  with  chloroform, 
which  readily  dissolves  the  freshly  formed  indigo,  and  sepa- 
rates from  the  aqueous  solution  as  a  blue  fluid,  the  color 
being  more  or  less  deep  according  to  the  amount  of  indican 
present.  In  pale  urines,  often  very  rich  in  indican,  this 
method  will  serve  to  determine  its  amount  with  sufficient 
accuracy  for  clinical  purposes.  Dark  urines,  whose  other 
coloring  matters  are  also  decomposed  by  hydrochloric  acid 
and  calcic  hypochlorite,  should  first  be  decolorized  by  a  solu- 
tion of  the  basic  acetate  of  lead,  avoiding  a  great  excess  of 
the  latter,  when,  if  indican  is  present,  a  good  indigo  extract 
can  be  obtained  in  this  way. 

Albumen  must  always  be  separated  before  performing  the 
analysis. 

*  Op.  cit.it.,  p.  101,  ad  fin. 

f  E.  S.  Wood,  M.D.,  in  Boston  Medical  and  Surgical  Journal, 
February  7th,  p.  170,  from  Centralblatt  fur  Wiss.  M.-.I.,  No.  20, 
1877,  p.  357. 


64        PRACTICAL   EXAMINATION   OF   THE   URINE. 

Clinical  Significance  of  Indican  in  the  Urine. 

An  increase  of  indican  is  found  in  renal  diseases,  espe- 
cially the  acute,  in  pyelitis,  diseases  of  the  spinal  cord  and 
its  membranes,  and  especially  derangements  of  the  entire 
central  and  peripheral  nervous  system,  in  urina  spastica,  and 
after  coitus.  It  is  also  especially  abundant  in  the  urine 
secreted  during  the  reaction  from  cholera. 

It  has  been  found  by  Neftel  in  cases  of  cancer  of  the 
liver,  and  its  presence  in  large  quantities,  in  persons  affected 
with  malignant  tumors,  he  considered  pathognomic  of  cancer 
of  the  liver ;  by  Hoppe-Seyler,  in  a  case  of  melanotic  cancer 
of  the  orbit.  Jaffe  finds  indican  increased  in  all  diseases 
attended  by  intestinal  obstruction,  cancer  of  the  stomach, 
lymphoma  and  lympho-sarcoma  in  the  abdomen,  purulent 
peritonitis,  certain  forms  of  diarrhoea,  and  in  various  diseases 
where  the  latter  is  a  symptom.  Rosenstein  found  indican 
increased  eleven  to  twelve  times  in  Addison's  disease. 

From  these  facts  it  is  evident  that  it  is  difficult  to  associate 
it  pathognomonically  with  any  disease.  But  recent  physio- 
logical observations  afford  a  rational  explanation  for  its  in- 
crease which  is  strikingly  confirmed  by  the  clinical  observa- 
tions above  noted.  It  was  discovered  by  Kiihne  (Virchow's 
Archiv.,  vol.  xxxix.)  that,  during  the  artificial  fermentation 
of  albumen  in  the  presence  of  minced  pancreas,  a  substance 
known  as  indol,  first  discovered  by  Baeyer,  was  produced. 
Jaffe  suggested  that  the  indol  thus  produced  during  digestion 
is  absorbed  and  oxidized  in  the  blood  to  indigo-blue,  com- 
bined with  sugar  and  excreted  as  the  glucoside  indican. 
Now  it  is  supposed  that  in  ordinary  normal  intestinal  diges- 
tion very  little  indol  is  produced  ;  but  wherever  digestion  is 
interfered  with  or  delayed,  as  is  evidently  likely  to  be  the 


ORGANIC   CONSTITUENTS.  65 

case  in  almost  all  of  the  conditions  above  instanced,  more  is 
produced,  absorbed,  oxidized,  and  excreted  as  indican,  thus 
accounting  for  its  presence  in  increased  amount  under  the 
circumstances. 

II.  Abnormal  Coloring  Matters. 

Under  abnormal  coloring  matters  are  included  those  which 
never  enter  into  the  composition  of  normal  urine,  whether 
found  elsewhere  in  the  body  or  not. 

They  include  a,  the  coloring  matters  of  blood,  haemoglobin, 
methamioglobin,  and  htematin.  Hzematin  is  a  deoxygenated 
hasmoglobin,  into  which  and  a  coagulated  albuminous  sub- 
stance, haemoglobin  is  converted  by  the  action  of  heat. 
Methaemoglobin  is  an  intermediate  condition,  approaching, 
however,  nearer  to  hoematin,  and  giving  the  same  absorption 
band,  in  the  yellow  of  the  spectrum  between  Fraunhofer's 
lines  C  and  D,  but  nearer  to  D,  while  hasmoglobin  gives  two 
bands  in  the  yellow  and  green  between  D  and  E.  b,  the 
ttroerythrin  of  Heller,  c,  vegetable  coloring  matters,  d, 
biliary  coloring  matters. 

a.     The   coloring   matters  of  the   blood,  hcemoglobin,    and 
methceinoglobin,  and  hcematin. 

These  substances  can  enter  the  urine  either  by  direct 
transudation,  or  arise  from  the  dissolution  of  blood  corpuscles 
themselves,  which  have  entered  the  urine  in  different  ways. 
They  may  be  present  in  urine  in  very  small  quantities  with- 
out being  accompanied  by  albumen,  as  was  first  shown  by 
Dr.  F.  A.  Mahomed.* 

*  Transactions  of  the  Royal  Modico-Chirurgical  Soc.  of  London, 
vol.  Ivii.,  1874,  p.  1915. 


66         PRACTICAL   EXAMINATION    OF   THE   URINE. 

The  color  of  the  urine  is  different  according  as  it  contains 
more  haemoglobin  or  methoemoglobin,  the  former  being 
brighter,  the  latter  darker,  brownish-red.  Hemorrhages 
from  the  larger  vessels  produce  more  haemoglobin;  capillary 
hemorrhages,  on  the  other  hand,  more  methaemoglobin.  Hel- 
ler proposes  to  account  for  the  difference  in  the  fact  that  in 
the  hemorrhages  which  take  place  from  the  capillaries  in  the 
course  of  renal  diseases,  the  blood  is  much  more  intimately 
and  more  slowly  commingled  with  the  urine,  and  therefore 
longer  retained  with  the  urine  at  the  normal  temperature  of 
the  body.  Temperature,  the  presence  of  carbonic  acid,  and 
the  absence  of  oxygen,  may  favor  the  passage  of  haemoglobin 
to  methaemoglobin. 

Detection  of  Blood  Coloring  Matters. 

1.  Of  small  quantities  of  Hcemoylobin  unaccompanied  by 
Albumen. — Dr.  Mahomed  (Op.  citat.}  directs  as  follows: — 
One  end  of  a  small  slip  of  white  blotting  paper  is  dipped  in 
the  urine  and  dried  over  the  flame  of  a  spirit  lamp ;  by  this 
means  the  dilute  solution  of  the  crystalloid  is  concentrated 
by  evaporation  ;  two  drops  of  the  tincture  of  guiacum  are 
then  dropped  on  the  paper,  and,  after  a  minute  or  so  allowed 
for  the  spirit  to  evaporate,  a  single  drop  of  ozonic  ether*  is  let 
fall  in  the  centre  of  the  guiacum  stain.  A  blue  color  appears 
if  haemoglobin  is  present.  Some  time,  perhaps  a  quarter  of 
an  hour  will  elapse  before  the  reaction  becomes  visible, 
especially  if  it  be  slight ;  when  it  appears  it  is  not  permanent ; 

*  Ozonic  ether  may  be  obtained  in  this  city  of  L.  Wolff,  apothe- 
cary, N.  W.  cor.  12th  and  Chestnut.  Both  it  and  the  tincture  of 
guiacum  should  be  freshly  prepared. 


ORGANIC    CONSTITUENTS.  67 

it  will  begin  to  fade  in  a  few  hours,  and  will  have  disap- 
peared in  a  day  or  two. 

The  advantage  of  this  test  lies  in  the  fact  that  the  phy- 
sician can  carry  a  few  slips  of  blotting  paper  in  his  pocket- 
book,  dip  one  in  the  urine  during  his  visit,  allow  it  to  dry 
and  make  the  test  at  home. 

Dr.  Stevenson's  modification  of  Dr.  Mahomed's  Test,  ac- 
knowledged by  the  latter  to  be  far  more  brilliant,  is  as  fol- 
lows : — To  a  drop  or  two  of  urine  in  a  small  test  tube,  add  one 
drop  of  the  tincture  of  guiacum  and  a  few  drops  of  ozonized 
ether  ;  agitate  and  allow  the  ether  to  collect  at  the  top,  form- 
ing an  upper  layer  of  fluid.  If  haemoglobin  be  present, 
the  ether  carries  up  with  it  the  blue  color  that  is  produced, 
leaving  the  urine  colorless  below.  In  this  method  the  blot- 
ting paper,  which  is  somehow  the  source  of  fallacy,  is  not 
required. 

Precautions — Saliva,  nasal  mucus,  and  a  salt  of  iodine 
(as  happens  when  the  patient  is  taking  iodide  of  potassium) 
all  strike  a  blue  color  with  tincture  of  guiacum,  some  with- 
out and  some  after  the  addition  of  ozonic  ether. 

Application By  this  test,  according  to  Dr.  Mahomed, 

infinitesimal  traces  of  haemoglobin  can  be  detected  in  urine, 
which  to  the  naked  eye,  the  microscope,  the  spectroscope, 
and  even  to  the  nitric  acid  test  for  albumen,  affords  no  indi- 
cation whatever  of  abnormality.  Indeed  the  presence  of 
albumen  in  any  quantity  interferes  jvith  the  test,  and  it  is  in 
the  prealbuminuric  stage  of  scarlatina,  or  just  after  it  has  dis- 
appeared and  where  there  is  a  high  state  of  vascular  tension, 
that  it  is  serviceable.  It  will  respond  in  chronic  albuminuria 
also,  where  minute  traces  of  blood  are  present.  Where  the 
response  precedes  the  appearance  of  albuminuria,  it  fades 


68        PRACTICAL   EXAMINATION   OF   THE   URINE. 

when  the  albumen  becomes  copious,  and  reappears  again  as 
it  diminishes  or  after  it  disappears. 

The  most  useful  application  of  the  test,  if  Dr.  Mahomed's 
views  are  sustained,  will  be  in  the  prealbuminuric  stage  of 
scarlatina,  where  it  will  give  us  information  of  a  state  of 
affairs  in  the  kidney  previous  to  actual  inflammation  of  the 
organ,  when  a  brisk  purge  or  copious  sweat  may  avert  more 
serious  mischief.  In  cases  of  albuminuria  produced  by  intense 
fever  and  due  to  venous  congestion,  as  in  enteric  fever,  pneu- 
monia, and  sometimes  in  the  febrile  stage  of  scarlatina,  when 
the  fever  is  intense  and  the  albuminuria  only  slight,  no  reac- 
tion showing  the  transudation  of  the  haemoglobin  can  be 
obtained. 

2.  Heller's  Hcematin  Test  is  as  follows :  Precipitate  from 
urine  in  a  test-tube  the  earthy  phosphates  by  caustic  potash 
and  gentle  heat  over  a  flame.  The  earthy  phosphates  carry 
with  them  as  they  sink  the  blood-coloring  matters,  and  ap- 
pear therefore  not  white  as  in  normal  urine,  but  blood-red. 
When  the  quantity  of  coloring  matter  in  urine  is  very  small 
the  earthy  phosphates  appear  dichroic.  If  the  urine  is 
already  alkaline,  and  no  precipitate  of  earthy  phosphate 
appears  on  the  addition  of  liquor  potasste  and  heat,  a  pre- 
cipitate can  be  artificially  produced  by  the  addition  of  one 
or  two  drops  of  the  magnesian  fluid,  which,  with  the  appli- 
cation of  heat,  carries  down  the  coloring  matters,  whence  it 
is  possible 

To  Prepare  Hcemin  Crystals If  the  precipitated  earthy 

phosphates  are  filtered  out  and  placed  on  an  object-glass,  and 
carefully  warmed  until  the  phosphates  are  completely  dry, 
Teichmann's  hosmin  crystals  can  be  produced  therefrom. 
For  this  purpose  a  minute  granule  of  common  salt  is  carried 
on  the  point  of  a  knife  to  the  dried  haematin  and  earthy 


ORGANIC   CONSTITUENTS.  69 

phosphate,  and  thoroughly  mixed  with  it.  Any  excess  of  salt 
is  then  removed,  the  mixture  is  covered  with  a  thin  glass 
cover,  a  hair  interposed,  and  a  drop  or  two  of  glacial  acetic 
acid  allowed  to  pass  under.  The  slide  is  then  carefully 
warmed  until  bubbles  begin  to  make  their  appearance.  After 
cooling,  hnemin  crystals  can  be  seen  by  aid  of  the  microscope, 
which,  though  often  very  small  and  incompletely  crystal- 
lized, are  easily  recognizable  by  sufficient  amplification. 

Precautions — Care  must,  however,  be  taken  to  apply 
only  a  gentle  heat  in  precipitating  the  earthy  phosphate 
with  caustic  potash  solution,  and  to  filter  quickly,  else  the 
hoematin  may  be  decomposed. 

It  sometimes  happens  also  that  vesicles  develop  under  the 
thin  glass  cover,  after  the  addition  of  acetic  acid,  even 
before  heat  has  been  applied.  These  are  carbonic  acid  which 
has  developed  out  of  the  earthy  phosphates.  These  should 
be  allowed  to  pass  away,  and  then  the  slide  warmed  until  the 
formation  of  vesicles,  that  is,  to  the  boiling-point  of  acetic 
acid. 

3.  Test  for  Hcematin  by  Precipitation  of  Albumen,  etc. — 
The  blood  coloring  matters  in  urine  may  also  be  demon- 
strated by  coagulating  the  albumen  by  boiling,  filtering 
off  the  brown  coagulum,  drying  and  treating  it  with  alcohol 
containing  sulphuric  acid.  .  This  alcoholic  solution  contains 
the  haematin,  and  if  the  alcohol  be  evaporated,  hiEmatin 
crystals  can  be  obtained  from  the  residue  in  the  manner 
above  described. 

Occurrence — Hrematinuria,  that  is  the  direct  passage  of 
the  coloring  matters  alone  from  the  blood  into  the  urine, 
occurs  in  certain  general  diseases,  as  scurvy,  purpura,  scar- 
latina, etc.  Haematuric  or  bloody  urine  occurs,  of  course, 
from  a  variety  of  causes  which  require  no  special  mention. 


70        PRACTICAL   EXAMINATION   OF   THE   URINE. 

b.    Uroerythrin. 

Heller  ascribes  the  well-known  dark  reddish-yellow  or 
"  high"  color  of  all  fever  urines  to  the  presence  of  a  sub- 
stance which  he  calls  uroerythrin,  as  well  as  to  an  increase 
of  the  normal  coloring  matters.  Except  that  it  contains  iron 
little  else  that  is  certain  is  known  with  regard  to  uroerythrin. 
To  it  he  ascribes  the  reddish  color  which  so  often  character- 
izes the  deposits  of  urates  known  as  "  lateritious ;"  if  the 
supernatant  urine  in  such  cases  be  treated  with  solution  of 
neutral  acetate  of  lead,  the  precipitate  presents  a  similar 
"  rosy  red"  or  "  flesh  color,"  which  he  attributes  to  the  same 
substance.  It  is  doubtless  a  modified  hoematin,  being  found 
especially  in  diseases  where  there  is  evident  blood  dyscrasia, 
as  in  low  fevers,  septic  conditions,  etc.  It  so  far  at  least 
corresponds  with  the  urohaematin  of  Harley  that  it  is  a 
measure  of  the  destruction  of  the  blood-corpuscles,  though  it 
will  be  remembered  that  the  urohsematin  of  Harley  is  looked 
upon  as  a  normal  constituent  of  urine  which  may  be  abnor- 
mally increased,  while  uroerythrin,  although  a  modified 
hsematin,  is  still  not  considered  identical  by  its  discoverer. 

Detection — Uroerythrin  is  known  to  be  present  by  its 
pink  coloration  of  the  "  lateritious"  sediment,  or  by  its  pre- 
cipitation by  solution  of  neutral  acetate  of  lead.  Too  much 
lead  solution  must  not  be  added  lest  the  precipitate  be  too 
abundant,  and  therefore  the  coloring  matter  be  rendered  less 
distinct  by  its  being  disseminated  over  a  large  amount  of 
deposit.  If  the  urine  contains  lumnatin  or  the  coloring  mat- 
ter of  blood,  it  must  first  be  removed. 

Precautions 1.    The  froth   of  a   urine   highly  charged 

with  uroerythrin  may  appear  yellow,  as  that  of  urine  con- 
taining biliary  coloring  matter,  but  the  precipitate  of  the 


ORGANIC    CONSTITUENTS.  71 

latter  by  acetate  of  lead  is  also  yellow  and  not  pink  as  with 
uroery thrin. 

2.  The  earthy  phosphates  which  are  precipitated  on  heat- 
ing the  urine  with  caustic  potash",  are  dirty  gray  when  the 
urine  contains  uroerythrin,  while  in  urine  containing  haema- 
tin  they  are  "blood  red"  or  dichroic.  The  absence  of 
albumen  from  the  urine,  the  gray  coloration  of  the  earthy 
phosphates,  and  the  red  precipitate  with  solutions  of  lead, 
serve  as  points  in  the  differential  diagnosis  between  uroery- 
thrin and  the  coloring  matter  of  the  blood. 

Clinical  Significance — Uroerythrin  is  found  in  the  urine 
in  all  febrile  affections,  even  the  slightest  catarrh ;  especially 
in  pyaemia,  diseases  of  the  liver,  and  lead  colic.  All  urine, 
according  to  Heller,  which  contains  uroerythrin  must  be 
abnormal. 

c.    Vegetable  Coloring  Matters. 

The  coloring  matter  of  plants,  especially  chrysophanic  acid 
found  in  rhubarb  and  senna  leaves,  contributes  to  alkaline 
urine  a  reddish-yellow  to  a  deep  red  color.  It  can  be  recog- 
nized by  the  fact  that  the  red  alkaline  urine  by  the  addition 
of  an  acid  becomes  yellow,  and  by  the  addition  of  an  excess 
of  ammonia  again  takes  on  the  red  color. 

Precautions Such  precipitation  by  heat  and  potash 

solution  might  possibly  be  taken  for  blood  coloring  matters. 
But  the  absence  of  albumen  from  the  urine,  the  production  of 
the  red  color  by  addition  of  an  excess  of  ammonia,  and  its 
paling  on  the  further  addition  of  an  excess  of  acid,  serve  to 
distinguish  this  vegetable  coloring  matter  from  blood  coloring 
matter  and  uroerythrin. 

Numerous  other  vegetable  matters  color  the  urine,  among 
which  santonin  is  conspicuous  for  the  bright  yellow  color  it 


72         PRACTICAL   EXAMINATION   OF   THE   URINE. 

produces  in  acid  urine,  while  the  staining  of  linen  by  it 
closely  resembles  that  of  biliary  coloring  matter.  Dr.  W. 
G.  Smith  (Dub.  Quar.  Jr.  Med.  Sci.,  Nov.  1870)  has  in- 
vestigated the  subject,  and  found  that  the  addition  of  an 
alkali  causes  the  development  of  &jine  red  cherry  or  crimson 
color,  according  to  the  amount  of  santonin  present ;  but  it 
will  be  observed  that  this  reaction  is  that  of  the  vegetable 
coloring  matters  generally,  as  above  described. 

Madder,  gamboge,  rhubarb,  logwood,  carrots,  whortleber- 
ries, etc.,  give  to  urine  more  or  less  of  their  peculiar  color. 

d.  Biliary  Coloring  Matters The  Detection  of  Bile  in  the 

Urine. 

When  bile  is  abundantly  present  in  urine,  the  yellow  color 
of  the  fluid,  and  especially  of  the  froth  or  foam  produced  by 
shaking,  is  sufficient  to  excite  suspicion.  Further,  if  a  piece 
of  filtering-paper  or  a  piece  of  linen  be  moistened  with  such 
urine,  it  retains  a  permanent  yellow  color  on  drying. 

The  only  positive  proof  of  the  presence  of  the  coloring 
matters  of  bile  in -the  urine  is  found  in  Gmelin's  or  Heller's 
test  for  the  unaltered  coloring  matters. 

Gmelin's  Nitrous  Acid  Test  is  performed  in  two  ways  : — 

First.  A  quantity  of  urine  is  placed  in  a  test-tube,  and 
a  small  quantity  of  fuming  nitric  acid  (nitrous  acid  of  com- 
merce) is  allowed  to  pass  carefully  down  the  sides  of  the 
test-tube  to  underlie  the  urine  as  described  in  Heller's  test 
for  albumen.  If  biliary  coloring  matters  are  present,  at  the 
point  of  union  between  the  urine  and  the  acid  will  very  soon 
be  seen  a  set  of  colors  which,  if  typical,  should  be  green,  blue, 
violet-red,  and  yellow,  or  yellowish-green  again  in  the  order 
named  from  above  downward.  Often,  however,  one  or  more 


ORGANIC   CONSTITUENTS.  73 

colors  are  wanting.  The  green  is  most  constant,  and  the 
first  green  indispensable  to  prove  the  presence  of  bile,  but 
violet  shading  into  red  and  yellow  is  also  very  constantly 
seen. 

Second.  Equally  satisfactory  is  the  test  if  a  few  drops  of 
the  urine  are  placed  upon  a  porcelain  plate,  and  as  much  of 
the  fuming  acid  placed  adjacent  and  allowed  gradually  to 
approach  the  urine.  The  same  play  of  colors  occurs. 

E.  Fleischl  (Boston  Med.  and  Surg.  Journal,  Jan.  13, 
1876,  from  Centralblatt  filr  die  Medicinischen  Wissen- 
schaften,  1875,  No.  34)  recommends  a  modification  of 
Gmelin's  test  by  which  it  is  made  more  delicate.  Instead 
of  having  impure  nitric  acid  added  in  such  a  way  that  it  will 
form  a  separate  layer  at  the  bottom,  the  urine  should  be 
thoroughly  mixed  with  pure  nitric  acid,  or  still  better,  with 
a  solution  of  the  nitrate  of  sodium,  and  then  concentrated 
sulphuric  acid  should  be  carefully  added  so  as  to  form  a  sepa- 
rate layer  at  the  bottom.  The  play  of  colors  forms  at  the 
junction  of  the  urine  and  sulphuric  acid.  The  advantage  of 
this  modification  is  that  the  pigment  is  not  oxidized  so 
rapidly,  and  therefore  the  color  is  not  changed  so  quickly 
and  is  not  so  liable  to  be  overlooked. 

Heller's  Test  for  Bile  Pigment — Pour  into  a  test-tube 
about  6  c.  c.  (1.6  f  5)  of  pure  hydrochloric  acid,  and  add  to  it, 
drop  by  drop,  just  sufficient  urine  to  distinctly  color  it.  The 
two  are  mixed  and  "underlaid"  as  before  with  pure  nitric 
acid,  and  at  the  point  of  contact  between  the  mixture  and  the 
colorless  nitric  acid,  a  handsome  play  of  colors  appears.  If 
the  "  underlaid"  nitric  acid  is  now  stirred  with  a  glass  rod, 
the  set  of  colors  which  were  superimposed  upon  one  another 
now  appear  alongside  of  each  other  in  the  entire  mixture, 
and  should  be  studied  by  transmitted  light.  Heller  further 
7  ' 


74        PEACTICAL   EXAMINATION   OF   THE   URINE. 

says,  if  the  hydrochloric  acid  on  addition  of  the  biliary 
urine  is  colored  reddish-yellow,  the  coloring  matter  is  biliru- 
bin  ;  on  the  other  hand,  if  it  is  colored  green  it  is  biliverdin. 

If  the  amount  of  coloring  matter  is  very  small,  a  large 
quantity  of  urine  .should  be  shaken  with  chloroform ;  the 
chloroform  allowed  to  separate  at  the  bottom  of  the  vessel  in 
large  drops.  The  yellow-colored  chloroform  is  then  re- 
moved by  means  of  a  pipette,  washed  with  distilled  water, 
and  poured  into  a  beaker-glass  containing  hydrochloric  acid. 
The  yellow  drops  of  chloroform  sink  to  the  bottom.  If  now 
while  diligently  shaking  the  glass,  nitric  acid  is  added,  the 
changes  of  color  can  be  distinctly  observed  in  the  chloro- 
form. In  consequence  of  the  slower  action  of  the  acid  upon 
the  coloring  matters  dissolved  in  the  urine  and  the  conse- 
quent slower  transition  of  colors,  this  method  is  peculiarly 
adapted  for  demonstration. 

Precautions 1.  With  neither  test  should  too  dark-hued 

a  urine  be  employed,  but  it  should  first  be  diluted  with 
water. 

2.  Should  albumen   be  present,  the  opaque  zone  at  the 
point  of  contact  between  the  urine  and  acid  imbibing  the 
coloring  matters  will  exhibit  a  green  coloration,  and  so  in  no 
way  interfere  with  the  test. 

3.  Urine  rich  in  indican  may,  however,  deceive,  forming 
at  the  point  of  contact  a  blue  layer  of  indigo,  which,  along 
with  the  yellow  urine  in   reflected  light,  may  appear  green. 
In  these  doubtful  cases  the  chloroform  modification  of  the 
test  should  be  used,  or  the  urine  may  be  precipitated  with 
solution  of  acetate  of  lead,  and  the  filtrate  examined  for 
indican. 

4.  The  earthy  phosphates,  precipitated  from  biliary  urine 
by  liquor  potassae  and  heat,  exhibit  a  brown  coloration. 


ORGANIC    CONSTITUENTS.  75 

Test  for  Decomposed  Biliary  Coloring  Matters — Should 
the  urine  contain  only  altered  biliary  coloring  matters  which 
respond  neither  to  Gmelin's  or  Heller's  test,  it  may  be  tried 
as  follows  : — 

A  piece  of  white  linen  or  filtering-paper  is  immersed  in 
the  suspected  urine,  and  allowed  to  dry,  when  it  will  appear 
colored  brown.  A  further  confirmation  that  the  decomposed 
coloring  matters  are  present  will  be  found  in  a  low  specific 
gravity  and  a  dark  urophain  reaction.  If,  moreover,  the 
urine  be  treated  with  liquor  potassao  and  heat,  to  precipitate 
the  earthy  phosphates,  it  becomes  darker  than  before  and  the 
phosphates  are  precipitated  brown. 

Bile  pigments  have  a  property  of  adhering  to  precipitates 
much  more  powerfully  than  other  pigments,  and  therefore 
sometimes  cannot  be  detected  in  fluid  urine  when  they  may 
be  in  precipitates.  Hence  Dr.  J.  F.  Tnrchanoff  (Central- 
blatt  fur  die  Medicinischen  Wissenschaften,  1875,  No.  6) 
recommends,  in  order  to  separate  with  certainty  the  biliary 
from  the  urinary  pigments,  precipitating  the  urine  with 
milk  of  lime,  freeing  from  excess  of  lime  by  a  current  of 
carbonic  acid  gas,  allowing  the  whole  to  stand  a  few  hours, 
filtering,  and  washing  the  precipitate  with  water.  The  bile 
pigments  are  contained  in  the  precipitate,  while  the  indican, 
hnemogloben,  and  methremogloben  are  in  the  filtrate.  The 
precipitate  is  then  dissolved  in  acetic  acid  and  tested  by 
Gmelin's  test. 


76         PRACTICAL   EXAMINATION   OF    THE   URINE. 


X.   THE  BILIARY  ACIDS. 

From  a  perusal  of  almost  all  of  the  existing  text-books  on 
physiology,  and  even  of  numerous  manuals  on  the  examina- 
tion of  urine,  the  student  is  led  to  suppose  that  the  detection 
of  bile  acids,  if  present  in  urine,  by  means  of  what  is  called 
Pettenkofer's  test,  is  one  of  the  easiest  possible.  On  the 
other  hand,  nothing  is  farther  from  the  truth,  and  the  fact 
is  that  such  detection  by  the  direct  application  of  the  elements 
of  Pettenkofer's  test  in  urine,  or  any  other  animal  fluid,  is 
practically  impossible,  even  if  the  bile  acids  are  present  in 
considerable  amount.  Nor  have  any  of  the  modifications  of 
Pettenkofer's  test,  recently  announced  as  clinically  available, 
proved  such  in  my  hands,  even  where  the  elements  of  bile 
have  been  added  to  the  urine,  except  where  inspissated  ox- 
bile  has  been  used.  The  results  of  a  complete  investigation 
of  this  subject  in  its  practical  bearings  will  be  found  in  a 
clinical  lecture  by  the  writer,  in  the  Philadelphia  Medical 
Times,  for  July  5,  1873,  "  On  a  case  of  Jaundice,  with 
remarks  on  the  availability  of  Pettenkofer's  Test,"  to  which 
the  student  is  referred.  In  these  experiments  the  simplest 
method  of  obtaining  the  biliary  acids  was  found  to  be  as  fol- 
lows :  Six  or  eight  ounces  (180-240  c.  c.)  of  the  suspected 
urine  are  evaporated  to  dry  ness  over  a  water-bath.  The 
residue  thus  obtained  is  treated  with  an  excess  of  absolute 
alcohol,  filtered,  and  the  filtrate  treated  with  an  excess  of 
ether  (12  to  24  times  its  bulk),  by  which  the  bile-acids,  if 
present,  are  precipitated.  These  are  then  removed  by  filtra- 
tion and  re-dissolved  in  distilled  water.  The  solution  is 
then  decolorized  by  passing  through  animal  charcoal  the 
resulting  colorless  fluid,  tried  by  Pettenkofer's  test  as  fol- 


ORGANIC   CONSTITUENTS.  77 

lows :  A  single  drop  of  a  20  per  cent,  solution  of  cane-sugar 
(simple  syrup  of  the  Pharmacopoeia  is  many  times  too 
strong)  is  then  added  to  a  drachm  or  two  (3.7-7.4  c.  c.)  in 
a  test-tube  or  porcelain  capsule.  Sulphuric  acid  is  then 
added  drop  by  drop,  while  the  test-tube  is  kept  in  a  vessel 
of  cold  water,  to  prevent  too  great  a  rise  in  temperature, 
which  should  not  exceed  50°-70°  C.  (122°-158°  F.).  As 
the  quantity  added  approaches  a  bulk  equal  to  that  of  the 
fluid  tested,  a  beautiful  cherry-red,  or  purple-violet  color 
should  make  its  appearance.  So  soon  as  a  yellow  color 
makes  its  appearance,  then  the  sulphuric  acid  is  acting  on 
the*sugar,  and  the  cherry-red  can  no  longer  be  looked  for. 
This  carbonizing  of  the  sugar  is  obviated  by  keeping  the 
temperature  down  to  the  degree  mentioned. 

Even  this  method  involves  more  time  than  is  often  avail- 
able to  the  active  practitioner,  but  there  is  none  more  simple, 
and  there  is  really  rarely  any  necessity  for  any  other  than 
the  color  test,  for  the  presence  of  the  biliary  acids,  although 
undoubtedly  occurring,  is  very  rare,  and  the  circumstances 
under  which  they  occur  are  illy  determined.  It  is  not  true, 
as  was  once  supposed,  that  they  are  always  present  in  the 
urine  in  cases  of  obstruction,  and  consequent  reabsorption 
of  bile,  and  absent  in  cases  of  suppression,  else  would  the 
determination  of  their  presence  be  of  real  value  in  diagnosis. 
The  only  circumstances  under  which  they  are  undoubtedly 
present  in  the  urine  are  as  rapidly  destructive  diseases  of 
the  liver,  as  acute  yellow  atrophy,  and  phosphorus  poisoning. 


78         PRACTICAL   EXAMINATION   OF   THE   URINE. 


XI.   LEUCIN  AND  TYROSIN. 

Leucin  and  tyrosin,  products  of  a  retrograde  metamorpho- 
sis of  nitrogenous  substances,  are  found  physiologically  only 
in  certain  fetid  secretions,  as  those  of  the  axilla  and  between 
the  toes,  but  can  be  produced  by  chemical  means  from  some 
glands,  as  the  liver,  pancreas,  and  spleen,  where  they  also 
occur  in  certain  pathological  states.  They  are  found  in  the 
urine  chiefly,  in  rapidly  destructive  diseases  of  the  liver,  as 
acute  yellow  atrophy,  or  phosphorus  poisoning,  but  occasion- 
ally also  in  typhus  and  smallpox.  They  always  accompany 
a  large  amount  of  biliary  coloring  matter,  and  the  presence 
of  albumen.  When  at  all  abundant,  as  they  generally  are  in 
acute  yellow  atrophy,  they  are  deposited  from  the  urine  and 
are  found  in  the  sediment,  the  former  in  the  shape  of  centri- 
cally  marked  spheres,  arranged  in  warty  masses,  or  druses, 
the  latter  in  needles.  (Fig.  18.) 

Schultzen  has  shown*  that  in  animals  poisoned  by  phos- 
phorus, "  urea  disappears  from  the  urine,  and  is  replaced  by 
leucin  and  tyrosin,  which  in  the  healthy  organism  are  con- 
verted into  urea."  A  similar  substitution  takes  place,  in 
cases  of  acute  atrophy  of  the  liver,  the  retained  urea  account- 
ing* for  the  convulsive  attacks  which  usually  precede  death 
in  these  cases. 

Detection If  the  crystals,  to  be  more  fully  described  in 

treating  of  sediments,  do  not  present  themselves  in  the 
spontaneous  deposit  of  such  cases,  the  evaporation  of  a  small 
quantity  of  the  urine  will  generally  promptly  display  them. 

*  Boston  Medical  and  Surgical  Journal,  July  23,  1874,  from 
Zeitschrift  fur  Biologie,  viii,  124,  and  Berliner  Wochenschrift,  1872, 
p.  417. 


ORGANIC    CONSTITUENTS.  79 

If  they  are  not  sufficiently  abundant  to  be  thus  demon- 
strated, the  method  of  Frerichs  must  be  pursued  to  separate 
them.  A  large  amount  of  urine  is  precipitated  with  basic 
acetate  of  lead,  filtered,  the  excess  of  lead  removed  from  the 
filtrate  by  sulphuretted  hydrogen,  and  the  clear  fluid  evapo- 
rated over  a  water-bath  to  a  small  volume.  In  twenty-four 
hours  tyrosin  needles  will  be  found  to  have  crystallized  out, 
but  leucin  spheres  will  not  appear  until  later,  on  account  of 
their  greater  solubility.* 


XII.  UREA.     CN2H4O. 

The  chief  organic  constituent  of  the  urine  and  the  index 
of  nitrogenous  excretion,  the  quantity  of  urea  fluctuates 
with  changes  in  the  quantity  and  composition  of  ingesta,  and 
with  the  rapidity  of  tissue  metamorphosis  in  health  and  dis- 
ease. A  range  of  from  20  to  40  grammes  (308.6  to  617.2 
grains)  must  at  least  be  admitted  in  adults. 

Detection  and  Estimation The  odor  of  urine  highly 

charged  with  urea,  may  be  said  to  be  characteristic,  but 
certain  evidence  of  its  presence  can  only  be  obtained  by 
treating  the  solution  suspected  to  contain  it  with  nitric  or 
oxalic  acid.  Though  crystallizing  itself  in  glistening  needles, 
it  is  too  soluble  to  permit  of  easy  detection  by  its  own  form. 
If  it  be  desired  to  detect  its  presence  in  a  suspected  fluid,  a 
drop  or  two  is  placed  upon  a  glass  slide,  a  drop  of  nitric  acid 
added,  the  slide  carefully  warmed  over  a  spirit  lamp,  and 
placed  aside  to  crystallize.  If  urea  is  present,  the  micro- 

*  Leucin  and  tyrosin  are  more  fully  treated  by  the  writer  in  the 
American  Journal  of  the  Medical  Sciences  for  January,  1872.  The 
above  is  believed  to  be  sufficient  for  practical  purposes. 


80        PRACTICAL   EXAMINATION   OF   THE   URINE. 

scope  will  reveal  singly  or  in  plates  six-sided  and  quadrilat- 
eral crystals  of  nitrate  of  urea,  Fig.  7.  The  crystals  have 
acute  angles  measuring  about  82°,  and  are  so  characteristic 
as  to  be  easily  recognizable ;  the  plates  often  overlap  each 
other  like  the  shingles  of  a  roof. 

FIG.  7.    (After  Beale.) 


Crystals  of  nitrate  of  urea. 

Solution  of  oxalic  acid  produces  similar  but  less  regular 
crystals  of  oxalate  of  urea. 

In  ordinary  healthy  urine,  this  crystallization  does  not 
take  place  unless  the -urine  is  concentrated  by  evaporation. 
But  in  some  urines  highly  charged  with  urea,  it  is  simply 
necessary  to  add  nitric  acid  to  produce  the  crystals,  and  thus 
is  arrived  at  a  rough  quantitative  estimation  for  urea. 

As  urea  is  by  far  the  most  abundant  solid  constituent  of 
the  urine,  it  follows  that  the  specific  gravity  may  become  a 
means  of  approximately  estimating  its  amount,  especially 
when  there  is  no  sugar  present,  if  the  quantity  of  albumen  is 


ORGANIC    CONSTITUENTS.  81 

small,  and  that  of  the  chlorides  is  normal.  A  specimen  of 
urine,  containing  neither  albumen  or  sugar,  a  normal  pro- 
portion of  chlorides,  and  a  specific  gravity  of  1020-4  to  a 
quantity  of  1500  c.  c.  (50  oz.),  in  twenty-four  hours  may  be 
taken  as  a  standard  normal  specimen  containing  2  per  cent, 
to  2^  per  cent,  of  urea.  These  conditions  being  observed,  a 
higher  specific  gravity  would  indicate  an  increased  propor- 
tion of  urea,  and  a  lower  diminished  proportion.  Under 
these  circumstances,  a  specific  gravity  of  1014  indicates 
about  1  per  cent,  of  urea,  and  of  1028  to  1030  about  3  per 
cent. 

But  the  chlorides  fluctuate  markedly  in  some  diseases, 
and  by  far  the  largest  proportion  of  urines,  in  which  a 
knowledge  of  the  amount  of  urea  is  important,  contain  albu- 
men. Next  to  urea,  supposing  albumen  and  sugar  absent, 
the  chlorides  most  affect  the  specific  gravity,  being  separated 
to  the  amount  of  10  to  16  grammes  (154  to  247  grains),  or 
§  to  1  per  cent,  in  the  24  hours.  If  these  are  totally  absent, 
as  they  often  are  in  pneumonia  and  other  febrile  diseases, 
characterized  by  an  increase  in  the  elimination  of  urea,  then 
must  a  specific  gravity  of  1020  indicate  more  than  2^  per 
cent,  of  urea,  or  if  the  percentage  of  chloride  replaced  by 
urea  be  added,  3^  per  cent.  This  is  supposing,  of  course,  as 
is  the  case,  that  the  remaining  constituents,  uric  acid,  cre- 
atinin,  phosphates,  sulphates,  etc.,  have  little  influence  on 
the  specific  gravity. 

If  albumen  is  present  in  small  quantity,  not  exceeding  ^ 
per  cent,  as  determined  by  the  approximative  method  given 
for  albumen,  it  has  little  effect,  and  it  can  be  thrown  out  of 
the  question.  If,  however,  the  albumen  be  more  abundant, 
1  to  2  per  cent.,  it  must  first  be  removed  by  coagulation  and 
filtration,  and  the  approximate  estimation  be  made  from  the 


82         PRACTICAL    EXAMINATION    OF   THE    URINE. 


3ific  gravity  of  the  filtrate  after  cooling.  Care  must  of 
course  be  taken  to  wash  the  coagulum  by  further  addition  of 
water  until  the  quantity  of  fluid  originally  operated  with  is 
restored.  After  such  removal  of  albumen,  if  not  before  it, 
the  specific  gravity  will  generally  be  found  diminished,  show- 
ing what  volumetric  analysis  has  determined  more  precisely, 
that  in  chronic  albuminuria,  at  least,  the  quantity  of  urea  is 
generally  diminished. 

Where  sugar  is  present  the  percentage  of  urea  is  also  gen- 
erally less,  though  with  increased  specific  gravity,  while  the 
large  total  quantity  of  urine  in  the  twenty -four  hours  may 
show  an  increase  in  the  total  urea  for  the  day.  There  is  no 
way  of  allowing  here  for  the  increased  specific  gravity  due 
to  the  presence  of  sugar,  and  the  only  way  to  arrive  at  a 
knowledge  of  the  amount  of  urea  is  by  volumetric  analysis. 

Volumetric  Analysis  for  Urea. 

Under  any  circumstances,  when  an  accurate  estimation 
of  urea  is  required,  we  must  have  recourse  to  volumetric 
analysis.  Several  methods  of  volumetric  analysis  for  ur"ea 
have  been  suggested,  of  which  that  of  Liebig,  with  the 
nitrate  of  mercury  solution,  seems  most  to  combine  'accuracy 
and  convenience.  Davy's  method,  with  the  sodium  hypo- 
chlorite  and  pure  mercury,  is,  in  some  respects,  more  simple, 
but  it  is  also  more  liable  to  error,  and  really  takes  more  time 
for  its  completion,  while  Liebig's  process  is  carried  out  with 
surprising  celerity,  after  even  a  little  experience,  not  more 
than  fifteen  minutes  being  required  to  complete  it  if  the  solu- 
tions are  at  hand. 

Liebig's  process  is  based  upon  the  fact  that  urea  produces 
an  insoluble  precipitate  with  mercuric  nitrate. 


ORGANIC    CONSTITUENTS.  83 

The  following  test-solutions  are  required  : 

1.  The  Baryta  Solution,  consisting  of  one  volume  of  cold 
saturated   solution  of  barium  nitrate,  with  two  volumes  of 
cold  saturated  solution  of  caustic  baryta  (baryum  hydrate). 

2.  A  saturated  solution  of  sodium  carbonate. 

3.  A    standard  solution   of   mercuric   nitrate  of    such 
strength  that  1  c.  c.  is  precisely  equivalent  to  .010  gramme, 
or  10  milligrammes  of  urea  (.15  grain). 

To  Prepare  the  standard  Solution  of  Mercuric  Nitrate.  1.  Dis- 
solve about  75  grammes  (1157.25  grs.)  of  pure  mercury  in 
pure  boiling  nitric  acid.  The  acid  fluid  is  concentrated  by 
evaporating  over  a  water-bath  to  a  syrupy  consistence,  and 
then  diluted  to  the  volume  of  a  litre  (2.1  pints)  of  distilled 
water.  Unless  a  great  excess  of  acid  remains  after  evapora- 
tion, a  white  precipitate  of  basic  nitrate  of  mercury  will  fall, 
which  must  be  removed  by  filtration  ;  previously,  however,  a 
few  drops  of  nitric  acid  should  be  added  which  will  dissolve 
the  greater  part  of  the  precipitate  without  making  the  solution 
too  acid.  The  solution  requires  to  be  graduated  by 

2.  The  standard  Solution  of  Urea.  Two  grammes  (30.86  grs.) 
of  pure  urea  should  now  be  dissolved  in  100  c.  c.  (27  f^)  of 
distilled  water,  of  which  10  c.  c.  (2.7  f3)  will  then  contain  0.2 
gramme  (3.08  grs.)  or  200  milligrammes. 

Ten  c.  c.  of  this  standard  solution  containing  200  milli- 
grammes of  urea  are  now  placed  in  a  beaker-glass.  A  burette 
is  then  filled  to  0  with  the  solution  of  mercuric  nitrate  (taking 
care  that  the  lower  edge  of  the  meniscus  which  forms  the  upper 
surface  of  the  liquid  corresponds  with  the  arrow  on  the  burette), 
which  is  then  allowed  to  drop  into  the  beaker,  where  it  will 
quickly  form  a  dense  precipitate.  When  the  precipitation 
seems  nearly  complete,  a  drop  of  the  fluid  containing  it  is 
allowed  to  fall  on  a  drop  of  the  solution  of  sodium  carbonate 
of  which  several  are  previously  ready  on  a  piece  of  glass  on  a 
dark  ground.  If  the  urea  is  not  completely  precipitated,  no 
change  of  color  takes  place.  The  cautious  addition  of  the 


84:        PEACTICAL   EXAMINATION   OF   THE   URINE. 

mercuric  nitrate  is  continued,  and  the  process  of  testing  with 
the  Na.2C03,  until  finally  a  yellow  oolor  appears.  This  proves 
that  the  mercuric  nitrate  has  been  added  in  excess, — consumed 
all  the  urea  in  combination  and  left  some  mercuric  nitrate  to 
react  with  the  sodic  carbonate,  which  it  does  by  forming  sodic 
nitrate  and  the  yellow  oxide  of  mercury. 

The  number  of  cubic  centimetres  consumed  in  reaching  the 
point  as  read  off  on  the  burette,  indicates  the  quantity  of  mer- 
curic nitrate  which  is  equivalent  to  200  milligrammes  of  urea. 
Whence  it  is  easy  to  calculate  how  much  further  the  solution 
should  be  diluted  to  make  10  c.  c.  =  100  milligrammes  of  urea 
or  1  c.  c.  =:  .010  gramme  (10  milligrammes). 

Thus  suppose  that  17.3  c.  c.  (4.67  f3)  of  the  solution  of  mer- 
curic nitrate  are  required  to  precipitate  the  .200  gramme  of 
urea;  then  if  2.7  c.  c.  (.73  f5)  water  are  added  to  this  quan- 
tity, we  will  have  20  c.  c.  =  .200  gramme  or  10  c.  c.  =  .100 
gramme  or  1  c.  c.  =  .010  gramme  or  10  milligrammes  as  re- 
quired. 

It  is  scarcely  necessary  to  say  that  the  quantity  (75  gms.) 
of  mercury  originally  taken  is  selected,  because  it  is  known 
that  that  amount  treated  as  above  and  diluted  to  a  litre  will 
give  very  nearly  the  proportion  required. 

Process Take  40  c.  c.  (10.8  f5)  urine  and  20  c.  c.  (5.4 

f5)  of  the  baryta  solution,  and  throw  them  into  a  beaker- 
glass.  By  this  means  the  phosphates,  sulphates,  and  car- 
bonates are  precipitated.  They  are  removed  by  filtration 
through  a  dry  filter,  and  if  the  filtrate  happen  not  to  be 
quite  clear,  it  may  be  passed  through  a  second  time.  While 
this  is  taking  place,  the  burette  is  filled  to  0  with  the  mer- 
curic nitric  solution,  and  15  c.  c.  (4.05  f5)  of  the  filtrate 
from  the  mixed  baryta  fluid  and  urine,  containing  of  course 
10  c.  c.  (2.7  f5)  of  pure  urine,  are  measured  off  into  a  small 
beaker-glass.  Into  this  the  mercuric  nitrate  solution  is 
allowed  to  fall  from  the  burette,  first,  a  number  of  cubic 


ORGANIC    COXSTITl'KXTS. 


85 


centimetres  approaching  the  last  two  figures  of  the  specific 
gravity  (that  is,  if  the  specific  gravity,  is  1017,  drop  say 
15  c.  c.)  before  testing  with  the  soda  solution.  If  no  yel- 

Fia.  8.    (After  Harley.) 


low  coloration  appears,  then  proceed  cautiously,  a  cubic 
centimetre  or  two  at  a  time,  testing  with  the  Na2CO3  until 
the  yellow  coloration  is  struck.  When  that  point  is  reached, 
read  off  the  number  of  cubic  centimetres  employed.*  The 

*  The  tinge  of  yellow  at  which  we  cease  the  titration  must  of 
course  be  the  same  as  that  at  which  in  originally  testing  the  nitrate 
of  mercury  solution  the  titration  was  stopped.  It  is  evident  that 
ceasing  the  titration  now  at  a  slight  tinge,  and  again  at  a  marked 
yellow  coloration,  must  give  rise  to  an  error,  which  practice  will 
soon  teach  the  student  to  avoid. 

8 


86        PRACTICAL   EXAMINATION   OF   THE   URINE. 

number  of  cubic  centimetres  of  mercury  solution  thus  used, 
minus  2,  multiplied  by  .010  gramme,  gives  the  amount  of 
urea  in  fractions  of  a  gramme  contained  in  10  c.  c.  (2.7  f'5) 
of  the  urine,  when  the  latter  is  of  average  composition, — 
that  is,  when  it  contains  no  abnormal  constituent,  and  the 
amount  of  chlorides  is  nearly  normal. 

The  two  cubic  centimetres  are  Jtrst  subtracted  because  it 
takes  about  this  quantity  to  decompose  the  chlorides  which 
first  form  a  soluble  precipitate  with  the  mercuric  nitrate,  and 
until  they  are  all  thrown  down,  the  combination  with  the 
urea  does  not  begin.  Hence  this  amount  must  first  be  sub- 
tracted. 

If,  however,  the  chlorides  are  not  of  average  amount,  but 
diminished  or  increased,  and  we  wish  to  be  accurate,  we  must 
first  estimate  the  amount  of  chlorides  calculated  as  NaCl  in  10 
c.  c.  of  the  urine,  by  the  process  to  be  explained  under  chlor- 
ides, and  from  a  fresh  quantity  of  urine  remove  the  whole  of 
the  chlorides  by  a  standard  solution  of  silver  nitrate.  For  this 
purpose  a  solution  of  nitrate  of  silver  is  required  of  such 
strength  that  1  c.c.  will  precipitate  10  milligrammes  sodium 
chloride.  29.075  grammes  (448.62  grs.)  of  fused  nitrate  of 
silver,  dissolved  in  distilled  water,  and  diluted  to  a  litre,  will 
be  such  a  fluid. 

In  10  c.c.  (2.7  f  5)  of  the  original  urine  we  determine  with 
the  nitrate  of  silver  solution  the  chloride  of  sodium  by  the 
method  for  the  determination  of  the  chlorides,  p.  96.  Sup- 
pose there  are  required  for  this  17.5  c.  c.  of  the  silver  solution, 
this  indicates  175  milligrammes  sodium  chloride. 

Take  now  30  c.  c.  (containing  20  c.  c.  of  urine)  of  the  filtrate 
from  the  mixture  of  baryta  fluid  and  urine,  add  a  drop  of  nitric 
acid,  and  then  17.5  X  2  c.  c.  =35  c.  c.  of  the  nitrate  of  silver 
solution.  This  will  precipitate  all  the  chlorides,  which  should 
be  removed  by  filtration,  and  the  filtrate  may  be  now  estimated 
for  urea.  It  is  important  always  to  bear  in  mind  the  exact 
amount  of  urine  operated  with  after  adding  the  nitrate  of  silver 


ORGANIC   CONSTITUENTS.  87 

solution  to  a  mixture  of  baryta  solution  and  urine,  of  which 
only  two-thirds  are  urine.  Thus  if  35  c.  c.  of  the  silver  solu- 
tion are  added  to  30  c.  c.  of  the  filtered  mixture  of  urine  and 
baryta  fluid,  of  the  resulting  65  c.  c.,  only  20  would  be  urine 
minus  the  chlorine,  or  out  of  32.5  c.  c.,  10  would  be  urine 
minus  the  chlorine. 

If  the  case  be  one  of  inflammation,  as  pneumonia,  where 
there  is  a  total  or  almost  total  absence  of  chlorides,  they  may 
be  thrown  out  of  the  question  altogether. 

Further  correction. — If  the  number  of  cubic  centimetres  of 
mercury  solution  added  to  15  c.  c.  of  the  mixture  of  urine  and 
baryta  fluid  exceeds  30 — that  is,  if  the  amount  of  urea  exceeds 
2  per  cent. — we  must  for  the  number  of  c.  c.  of  the  mercurial 
solution  above  30  add  half  the  number  of  c.c.  of  water  before 
testing  with  carbonate  of  sodium. 

If  the  urine  contains  less  than  2  per  cent  of  urea,  for  every 
5  c.  c.  of  the  test  solution  used  below  30,  there  should  be  de- 
ducted .1  c.  c.  from  the  entire  number  of  cubic  centimetres  of 
.  the  mercurial  solution  used. 

For  the  reasons  for  these  corrections  the  student  is  referred 
to  the  larger  works,  as  Neubauer  and  Vogel  or  Thudicum. 

Estimation  of  Urea  by  the  Hypobromite  Process — The 
principle  on  which  this  process  is  based — that  urea,  when 
brought  into  contact  with  hypochlorite  of  calcium,  is  decom- 
posed into  nitrogen,  carbonic  anhydride,  and  water — was 
suggested  many  years  ago  by  Davy.  Recently  Messrs.  Rus- 
sell and  West*  have  again  directed  attention  to  the  sub- 
ject, substituting  a  solution  of  hypobromite  of  sodium  and 
caustic  soda,  which  yields  similar  products ;  the  carbonic- 
anhydride  being  absorbed  by  the  caustic  alkali.  The  follow- 
ing is  the  reaction  : — 
CON2H4  +  3(NaBrO)  =  3(NaBr)  -f  CO2  -f-  2H2O  -f  N,. 

*  Journal  of  the  Chemical  Soc.  (London),  August,  1874. 


88         PRACTICAL   EXAMINATION    OF   THE    URINE. 

The  volume  of  nitrogen  disengaged  being  the  measure  of  the 
urea. 

Many  forms  of  apparatus  have  been  suggested  by  different 
experimenters,  all  based  upon  the  principle  that  operating 
with  0.15  grin,  of  urea,  the  barometer  being  at  30  and  the 
thermometer  at  GO0  F.  (15.5°  C.),  the  volume  of  nitrogen 
disengaged  was  found  to  be  55  c.  c.,  or  10  c.  of  gas  cor- 
responded to  .0027  grm.  urea. 


The  simplest  apparatus  would  seem  to  be  that  of  Dr.  G. 
Noel,  figured  in  the  text  and  first  described  in  the  Reper- 
toire de  Pharmacie*  (1877,  No.  22).  It  consists,  1st,  of 
a  mixing  vessel,  B,  graduated  into  cubic  centimetres,  and  a 
small  receiver,  C,  similarly  graduated  (this  graduation  is 
not  absolutely  necessary,  as  the  test  fluid  and  urine  may 
both  be  measured  by  a  volume  pipette  before  being  intro- 

*  Also  figured  and  described  in  New  Remedies,  March,  1878. 


ORGANIC    CONSTITUENTS.  89 

duct'd).  The  receiver  C  is  provided  with  a  central  open 
tube,  ending  at  D,  the  chief  use  of  which  is  to  retain  it 
in  an  upright  position.  2d,  of  a  taller  vessel,  A,  to  con- 
tain water,  into  which  is  immersed  an  elongated  bell-glass 
or  burette,  graduated  in  cubic  centimetres.  To  the  pointed 
open  end  of  this  a  piece  of  rubber  tubing  is  attached,  con- 
necting it  with  the  glass  tube  passing  through  the  rubber 
stopper  of  the  mixing  tube  B. 

The  alkaline  hypobromite  solution  used  is  made  by  dis- 
solving 100  grms.  of  caustic  soda  in  250  c.  c.  of  water,  and 
adding  25  c.  c.  of  bromine  to  the  solution  thus  produced. 
2NaHO  +  Br2  =  NaBr  +  H,O  +  NaBrO. 

Process.—  Introduce  into  the  receiver  C,  5  c.  c.  urine,  and  into 
the  mixing  vessel  15  c.  c.  of  the  hypobromite  solution,  being 
careful  not  to  mix  the  two  fluids.  Depress  the  graduated  tube 
into  the  vessel  A,  until  the  zero  mark  coincides  entirely  with 
the  surface  of  the  water,  and  connect  the  end  of  the  tube  by 
means  of  the  rubber  tube  with  the  tube  perforating  the  stopper 
of  the  mixing  vessel  B,  which  is  now  accurately  closed.  The  mix- 
ing tube  is  then  inclined  so  as  to  allow  the  urine  to  mix  with 
the  hypobromite  solution.  Effervescence  immediately  sets  in, 
and  as  it  proceeds,  the  measuring  tube  is  gradually  raised  to  re- 
lieve the  disengaged  nitrogen  of  the  hydrostatic  pressure.  The 
mixing  vessel  is  then  shaken  a  few  times,  and  when  the  reac- 
tion appears  complete,  the  apparatus  is  left  for  a  few  minutes 
until  it  has  acquired  the  temperature  of  the  room  in  which  the 
operation  has  been  performed.  The  water  within  and  without 
the  tube  is  again  levelled  and  the  cubic  centimetres  displaced 
by  the  gas  read  off.  Thus  suppose  10  cubic  centimetres  have 
been  read  off.  Then  5  c.  c.  urine  contain  .0027  X  10  =  .027 
grm.  ;  whence  can  be  calculated  either  the  percentage  or  the 
24  hours'  quantity. 

In  experiments  made  by  Messrs.  West  and  Russell,  Mr. 
Richard    Apjohn,    Dr.    Dupre,    Dr.    M.    Simpson,   Mr.    C. 


90        PRACTICAL   EXAMINATION   OF   THE   URINE. 

O'Keefe  and  others  with  solutions  containing  known  quanti- 
ties of  urea,  astonishingly  accurate  results  were  obtained, 
quite  sufficiently  so  for  clinical  purposes. 

M.   Depaine  (Journ.  de  Pharm.  d'Auv.,   1877)   recom 
mends  to  deduct  4.5  per  cent,  from  the  total  amount  of  urea 
found,  to  eliminate  the  error  caused  by  the  simultaneous 
decomposition  of  uric  acid  and  creatinin. 


When  uric  acid  is  spoken  of  as  a  constituent  of  normal 
urine,  it  is  never  to  its  free  state  that  allusion  is  made,  but 
to  its  combinations  chiefly  with  potash,  soda,  and  ammonia, 
but  also  with  lime  and  magnesia,  usually  known  as  mixed 
urates.  Uric  acid  itself  is  so  extremely  insoluble  (one  part 
requiring  14,000  of  cold  and  1800  of  hot  water  to  dissolve 
it)  that  it  is  immediately  precipitated  on  being  freed  of  its 
bases.  In  quantity  it  is  found  ranging  .4  to  .8  gramme 
((5.17  to  12.34  grs.)  in  the  twenty-four  hours,  in  health 
varying  pari  passu  with  urea  of  which  it  is  a  stage  short  in 
oxidation. 

Detection  by  the  Microscope — Its  presence  as  such  is 
recognized  by  the  microscopic  characters  of  its  crystals, 
which  in  their  typical  form  may  be  said  to  be  "  lozenge- 
shaped,"  or  as  best  described  by  the  Germans,  "  whetstone- 
shaped."  They  are,  moreover,  always  colored  yellowish-red 
or  red,  being  with  their  salts  the  only  urinary  deposits  thus 
stained,  so  that  when  a  sediment  is  seen  of  which  the  ele- 
ments are  thus  colored,  it  may,  without  hesitation,  be  put 
down  as  composed  of  uric  acid  or  its  combinations.  More 
will  be  said  of  these  crystals  in  treating  of  sediments,  where 
their  discussion  more  properly  belongs. 


ORGANIC    CONSTITUENTS.  91 

The  Murexid  Test — The  murexid  test  for  uric  acid  and 
its  combinations  is  one  of  extreme  beauty.  A  small  portion 
of  sediment,  or  the  residue  after  evaporation,  is  placed  on  a 
porcelain  plate  or  piece  of  platinum,  a  drop  or  two  of  nitric 
acid  added  to  dissolve  it,  and  then  carefully  evaporated  over 
a  spirit-lamp  flame.  When  dry,  a  drop  or  two  of  liquor 
ammonia  is  added,  when  there  promptly  appears  a  beautiful 
purple  color,  which  will  gradually  diffuse  itself  as  the  am- 
monia spreads.  The  murexid  reaction  is  believed  to  depend 
upon  the  origin  of  alloxan,  alloxantin,  and  ammonia,  under 
the  action  of  the  hot  nitric  acid.  This  reaction  is  also  said 
to  occur  with  tyrosin,  hypoxanthin,  and  xanthoglobulin,  and 
Schiff  accordingly  recommends  the 

Carbonate  of  Silver  Test  for  Uric  Acid. — This  is  very 
delicate,  and  is  most  conveniently  applied  as  recommended 
by  Harley.  Dissolve  a  little  uric  acid  in  a  solution  of 
sodium  or  potassium  carbonate,  place  a  drop  or  two  of  the 
solution  on  paper,  and  add  a  solution  of  nitrate  of  silver.  A 
distinct  gray  stain  promptly  occurring  indicates  the  presence 
of  uric  acid. 

Neither  of  the  tests,  however,  discriminates  between  uric 
acid  and  urates.  The  microscope  alone  can  do  this. 

Quantitative  Estimation  of  Uric  Acid. — To  200  c.  c. 
(54  f'5)  add  20  c.  c.  (5.4  f'5)  of  hydrochloric  or  nitric  acid, 
and  set  aside  in  a  cool  place,  as  a  cellar,  for  twenty-four 
hours.  At  the  end  of  that  time  the  uric  acid  crystals, 
highly  colored,  will  be  found  adhering  to  the  sides  and  at 
the  bottom  of  the  beaker.  Collect  the  uric  acid  on  a  weighed 
filter,  wash  thoroughly  with  distilled  water.  Dry  the  filter 
and  uric  acid  at  a  temperature  of  100°  C.  (212°  F.),  weigh, 
and  the  weight  of  the  two,  minus  the  weight  of  the  filter, 
will  be  the  weight  of  the  uric  acid  in  200  c.  c.,  except  the 


92         PRACTICAL   EXAMINATION   OF   THE   URINE. 

small  portion  retained  in  the  acid  and  washings.  Neubauor 
advises  to  add  to  the  result  0.0038  gramme  uric  acid  for 
every  100  c.  c.  of  these  fluids. 


XIV.   URATKS. 

It  has  already  been  said  that  in  health,  practically  all  the 
uric  acid  of  the  urine  is  held  in  combination  with  potash, 
ammonia,  soda,  lime,  and  magnesia,  of  which  those  with 
potash  and  ammonia  are  most  abundant  according  to  Bence 
Jones.  These  are  very  soluble  compounds  at  the  tempera- 
ture of  the  body,  but  are  precipated  in  amorphous  granules 
when  the  temperature  of  the  urine  is  lowered,  as  in  winter 
weather. 

Their  physiological  and  pathological  significance  depends 
altogether  upon  the  uric  acid  they  contain,  but  there  are 
some  points  of  reaction  with  which  the  student  should  be 
quite  familiar.  These  grow  out  of  the  fact  that  uric  acid  is 
a  bibasic  acid,  forming  neutral  and  acid  salts,  and  that  the 
acid  salts  are  much  less  soluble  than  the  neutral,  requiring 
124  parts  of  boiling  and  1120  parts  of  cold  water  for  their 
solution.  They  form,  therefore,  the  bulk  of  urate  deposits, 
while  urates,  which  remain  in  solution  after  such  reduction 
of  temperature  as  constantly  takes  place  in  an  apartment, 
must  be,  if  not  neutral,  at  least  less  acid  than  those  which 
form  the  sediment.  And  a  solution  remaining  for  some 
time  clear  under  such  circumstances,  must  contain  urates  of 
soda,  etc.,  with  a  large  proportion  of  the  alkaline  base. 

The  practical  application  of  this  fact  is  seen  in  this,  that 
when  an  acid  is  added  to  such  solution  of  neutral  urate,  by 
seizing  upon  a  portion  of  the  base,  it  leaves  an  acid  urate  of 


ORGANIC    CONSTITUENTS.  93 

s<nl;i,  which,  in  consequence  of  its  relative  insolubility,  is 
promptly  precipitated  in  a  finely  granular  form,  producing 
a  decided  opacity.  Now,  this  is  precisely  what  often  hap- 
pens in  the  nitric  acid  test  for  albumen.  The  urine  is  highly 
charged  with  neutral  urates  which  are  held  in  solution. 
Nitric  acid  is  added,  and  down  goes  a  precipitate,  not  crys- 
talline, but  amorphous,  which  is  composed  of  acid  urate  of 
soda.  And  if  Heller's  method  is  followed,  an  opaque  zone 
is  formed  at  the  point  of  contact  between  the  acid  and  urine, 
which  may  be  mistaken  for  albumen,  but  which,  besides  pre- 
senting certain  visual  characters  of  its  own,  which  have  been 
described,  p.  34,  is  readily  soluble  by  heat.  If  urine  pre- 
senting this  reaction  with  acid  be  allowed  to  stand  for  some 
time,  the  milky  opacity  gradually  passes  away,  and  is  sub- 
stituted by  a  very  small  crystalline  sediment  of  uric  acid. 
By  longer  action  of  the  acid,  the  remainder  of  the  base  is 
entirely  withdrawn,  leaving  the  free  acid,  which  is  deposited 
in  crystals.  It  has  already  been  stated  that  this  precipitate 
by  nitric  acid  is  considered  by  Thudicum  to  be  not  acid 
urates  but  hydrated  uric  acid. 

The  remaining  organic  constituents  of  the  urine,  creatinin, 
creatin,  xanthin,  hippuric  acid,  oxalic  acid,  lactic  acid,  and 
phenylic  acid,  having  little  practical  significance  as  such, 
require  only  to  be  mentioned  in  this  connection. 

Mucus  and  the  crystalline  combination  of  oxalic  acid  with 
lime  will  be  further  considered  in  treating  of  sediments. 

Hippuric  acid  is  interesting  in  forming  one  of  the  most 
striking  connecting  links  between  the  urine  of  carnivora, 
omnivora,  and  herbivora,  replacing  in  the  last  the  uric  acid 
of  the  first,  while  in  man,  who  consumes  a  mixed  diet,  we 
have  both  uric  acid  and  hippuric,  that  is,  an  intermediate 
state.  But  while  hippuric  acid  is  increased  in  man  by  a 


9-i         PRACTICAL   EXAMINATION    OF   THE   URINE. 

vegetable  diet,  yet  it  is  not  wholly  absent  with  animal  food. 
It  is  increased  in  diabetes,  where  also  it  almost  replaces  uric 
acid.  If  10  grains  benzoic  acid  be  taken  in  the  evening, 
the  next  morning  crystals  of  hippurie  acid  will  usually  be 
found  in  the  urine.  The  typical  form  of  these  is  a  four- 
sided  prism,  with  two  or  four  bevelled  surfaces  at  its  ends, 
but  from  this  there  are  deviations.  In  the  twenty-four 
hours'  urine  of  man,  .5  to  1  gramme  (7.7  to  15.4  grs.)  are 
separated. 

Inorganic  Constituents. 

XV.  THE  CHLORIDES. 

The  chlorides  found  in  the  urine  are  chiefly  those  ot 
sodium,  with  a  small  proportion  of  chloride  of  potassium  and 
ammonium. 

In  health  the  chlorides  are  almost  an  exact  measure  of  the  ' 
same   substances    taken    in  with   the  food,  and  amount  to 
10-16  grammes  (154.3  to  246.8  grs.)  in  the  24  hours. 

Detection  and  approximate  Estimation — If  a  drop  of 
urine  be  slowly  evaporated  on  a  glass  slide,  characteristic 
octahedral  crystals  and  rhombic  plates  of  a  combination  of 
urea  and  chlorine  make  their  appearance,  and  may  be  ex- 
amined by  the  microscope.  Jiut  more  available  for  detection 
and  approximate  estimation  is 

The  Nitrate  of  Silver  Test — Nitrate  of  silver  in  solution 
throws  down  both  the  phosphates  and  chlorides  from  the 
urine.  But  if  a  few  drops  of  nitric  acid  be  first  added,  the 
phosphates  will  be  held  in  solution,  and  only  the  chlorides 
will  fall  as  opaque  white  chloride  of  silver. 

From  normal  urine  containing  ^  to  1  per  cent,  of  chlorides, 


INORGANIC   CONSTITUENTS.  95 

they  are  precipitated  by  a  single  drop  of  a  solution  of  nitrate 
of  silver,  1  part  to  8,  in  cheesy  lumps,  which  do  not  further 
divide  themselves,  or  make  the  urine  more  milky  by  moving 
the  glass  about.  7/",  however,  the  chlorides  are  diminished 
to  y1^  per  cent,  or  less,  the  addition  of  a  single  drop  of  the 
silver  solution  no  longer  produces  the  white  cheesy  lumps, 
but  a  simple  cloudiness,  and  the  entire  fluid  appears  equally 
milky.  If,  finally,  there  should  be  no  precipitate  whatever, 
then  the  chlorides  are  totally  absent. 

The  presence  of  albumen  in  moderate  amount  does  not 
interfere  with  the  test,  but  if  abundant,  it  must  be  removed. 

Clinical  Significance — The  chlorides  are  diminished  in 
all  febrile  conditions,  whether  of  local  or  general  origin. 
Especially  is  this  the  case  where  there  are  any  exudations, 
solid  or  fluid,  by  which  they  seem  to  be  eliminated.  In 
acute  pneumonia,  where  they  are  often  totally  absent  from 
the  urine,  they  appear  abundantly  in  the  saliva.  In  this 
affection,  and  indeed,  in  all  acute  diseases,  their  disappear- 
ance from  the  urine  indicates  an  increment  in  the  disease, 
and  their  reappearance  an  improvement.  In  pneumonia  a 
decline  in  the  disease  may  often  be  detected  through  their 
return  before  physical  or  any  other  signs  point  to  improve- 
ment. Hence  a  daily  trial  of  the  urine  for  them  becomes 
important. 

Volumetric  Process  for  the  Chlorides. 

The  volumetric  process  employed  may  be  that  of  Liebig 
with  solution  of  mercuric  nitrate,  or  Mohr's,  with  silver 
nitrate. 

Mohr's  nitrate  of  silver  method  is  preferred  by  Neubauer,* 

*  Neubauer  and  Vogel,  Analyse  des  Hams,  vi.  Aufl.,  1872,  p. 
169. 


96        PRACTICAL   EXAMINATION   OF   THE   URINE. 

because    Liebig's   method,  if  not  very  exactly  carried   out, 
gives  incorrect  results.     There  are  required  : — 

1.  A   cold   saturated   solution    of    neutral    chromate    of 
potash. 

2.  A  solution  of  nitrate  of  silver,  such   that  1  c.  c.  =  10 
milligrammes   NaCl.     This   is   made  by  dissolving  29.07.5 
grammes   (448.62  grs.)  pure  fused  nitrate  of  silver  in  dis- 
tilled water,  and  diluting  to  a  litre. 

Process — Put  10  c.  c.  (2.7  f  5)  of  the  urine  in  a  platinum 
crucible,  dissolve  in  it  1  or  2  grammes  (15.43  or  30.86  grs.) 
potassium  nitrate,  free  from  chlorides,  and  evaporate  the  whole 
slowly  to  dryness.  Expose  the  remainder  first  to  a  gentle 
and  afterwards  to  a  strong  heat  until  the  carbon  is  completely 
oxidized,  and  the  residue  a  white  molten  saline  mass.  The 
entire  white  mass  is  then  dissolved  in  a  little  water,  placed 
in  a  beaker-glass,  the  platinum  capsule  washed  off  into  it 
with  the  wash-bottle.  Dilute  nitric  acid  is  then  carefully 
dropped  into  the  alkaline  fluid  until  it  is  faintly  acid,  a  small 
pinch  of  calcium  carbonate  is  then  introduced  to  make  it 
neutral,  and  the  excess  of  lime  filtered  off.  To  the  mixture, 
2  or  3  drops  of  the  potassium  chromate  solution  are  now 
added,  and  the  silver  solution  allowed  to  flow  in  from  the 
burette  while  stirring  the  mixture,  until  a  distinct  red  color 
remains.  The  color  continues  canary-yellow  until  all  the 
chlorides  are  decomposed.  As  each  drop  falls  into  the 
urine,  it  must  be  carefully  watched  for  the  least  tinge  of  red 
surrounding  the  precipitate  of  chloride  of  silver;  the  very 
next  drop  after  the  complete  decomposition  of  the  chlorides 
gives  a  permanent  red  color,  due  to  the  presence  of  silver 
chromate.  The  number  of  cubic  centimetres  consumed 
X.010  grm.  will  give  the  amount  of  chlorides,  estimated  as 
NaCl,  in  10  c.  c.  urine,  whence  the  total  is  calculated. 


INOKGANIC  CONSTITUENTS.  97 


XVI.  PHOSPHATES. 

The  phosphates  of  the  urine  are  composed  partly  of  earthy 
and  partly  of  alkaline  phosphates.  The  former  are  insoluble 
in  water,  but  soluble  in  acids ;  they  are  held  in  solution  in 
acid  urine  by  free  carbonic  acid,  and  precipitable  from  it  by 
alkalies.  The  alkaline  phosphates  are  soluble  in  water,  and 
not  precipitated  from  solution  by  alkalies. 

(a)  The  earthy  phosphates  are  phosphates  of  lime  and 
magnesia,  and  are  contained  in  urine  in  but  small  quantities 
— 1  to  1.5  gramme  (15.43  to  23.14  grains)  in  twenty-four 
hours. 

Detection  and  Approximate  Estimation The  presence 

of  the  earthy  phosphates  is  shown  by  adding  any  alkali  as 
caustic  ammonia  or  potash. 

Their  quantity  may  be  approximately  estimated  in  the 
following  simple  way,  given  by  Hoffmann  and  Ultzmann. 
A  test-tube,  16  centimetres  (6.2992  inches)  long  and  2  cen- 
timetres (.787  inch)  wide,  is  filled  one-third  with  clear  or 
filtered  urine,  to  which  a  few  drops  of  caustic  ammonia  or 
caustic  potash  solution  are  added  and  warmed  gently  over  a 
spirit-lamp  until  the  earthy  phosphates  begin  to  separate  in 
flakes.  It  is  then  placed  aside  for  ten  or  fifteen  minutes  for 
them  to  subside.  If  the  layer  of  sediment  is  one  centimetre 
(.3937  inch)  high,  the  earthy  phosphates  are  present  in  nor- 
mal amount ;  if  they  occupy  2  to  3  centimetres  (.787  to 
1.181  inch),  they  are  increased  ;  if,  on  the  other  hand,  only 
a  few  flakes  are  visible,  the  earthy  phosphates  are  diminished. 

Further,  in  normal  urine  the  earthy  phosphates  are 
precipitated  white,  but  if  the  urine  contains  abnormal 
coloring  matter,  they  fall  variously  colored.  If  the  urine 
9 


98         PRACTICAL   EXAMINATION   OF   THE   URINE. 

contains  blood  coloring  matter,  the  earthy  phosphates  appear 
blood-red  or  dicroic;  if  there  be  present  vegetable  coloring 
matters,  as  of  rhubarb,  senna,  etc.,  they  are  colored  rosy-red 
to  blood-red,  and  by  the  biliary  coloring  matters  yellowish- 
brown,  and  by  uroerythrin,  gray. 

The  earthy  phosphates  are  deposited  from  alkaline  urine, 
and  a  most  important  precaution  here  must  be  observed  not 
to  mistake  such  a  deposit  for  an  excess  of  phosphates.  The 
phosphates  may  really  be  diminished,  and  yet,  in  consequence 
of  the  reaction  of  the  urine,  a  copious  deposit  may  be  pre- 
sent. The  possible  precipitation  of  earthy  phosphates  by 
heat  alone  as  a  source  of  error  in  testing  for  albumen,  has 
already  been  alluded  to.  This  frequently  occurs,  and  is 
best  explained  on  the  supposition  of  Dr.  Brett,  that  the 
earthy  phosphates  are  held  in  solution  in  urine  by  carbonic 
acid,  which,  being  dissipated  by  heat,  allows  the  phosphates 
to  fall.  It  should  be  further  stated,  however,  that  Dr.  Owen 
Rees  believes  the  phosphates  are  held  in  solution  of  ammo- 
nium chloride,  which  would  also  be  dissipated  by  heat.  Dr. 
Bence  Jones  attributed  this  precipitation  to  a  neutralization 
of  the  excess  of  free  acid  in  the  urine  by  an  alkali  or  free 
sodium  phosphate. 

Clinical  Significance — The  earthy  phosphates  are  in- 
creased in  the  urine  by  diseases  of  the  bones,  especially  if 
extensive,  as  in  osteomalacia  and  rickets,  in  chronic  rheu- 
matoid arthritis,  in  diseases  of  the  nerve-centres,  and  after 
great  mental  strain  ;  but  especially  are  the  earthy  phosphates 
increased  by  the  food  and  drink,  some  contending  that  all 
variations  in  the  earthy  phosphates  are  due  to  this  cause. 
In  renal  diseases,  on  the  other  hand,  the  phosphates  are 
diminished.  Earthy  phosphates  are  often  found  deposited 


INORGANIC    CONSTITUENTS.  99 

in  conditions  of  dyspepsia  and  over-work,  but  this  may  gene- 
rally be  traced  to  changes  in  the  reaction  of  the  urine. 

(b)  The  alkaline  phosphates,  soluble  in  water  and  not  pre- 
cipitated by  ammonia  or  alkalies,  form  the  chief  bulk  of  the 
phosphates,  averaging,  according  to  Breed,  4  grammes  (61.72 
grains)  in  the  twenty -four  hours,  though  Neubauer,  by  volu- 
metric analysis,  has  seldom  found  more  than  two  grammes 
(30.86  grains)  in  this  period.  Four  grammes  correspond  to 
two  grammes  phosphoric  acid.  They  are  almost  wholly 
made  up  of  acid  sodium  phosphate,  with  possible  traces  of 
potassium  phosphate.  The  acid  sodium  phosphate  was 
believed  by  Liebig  to  be  the  cause  of  the  acid  reaction  of 
the  urine. 

Approximate  Estimation  of  Alkaline  Phosphates — Accu- 
rately to  estimate  the  alkaline  phosphates,  it  would  be  neces- 
sary, first,  to  remove  the  earthy  phosphates,  which  may 
easily  be  done  by  precipitating  them  with  ammonia  and 
filtering  out.  For  approximate  estimation,  however,  this  is 
not  necessary,  since  they  are  in  the  first  place  present  in 
comparatively  small  quantity,  and,  secondly,  do  not  vary 
much  in  disease.  Practically,  therefore,  they  are  disre- 
garded, and  to  a  suitable  quantity  of  urine  placed  in  a  beaker- 
glass  about  one-third  as  much  of  the  magnesian  fluid  (p.  16) 
is  added.  All  of  the  phosphates  are  thrown  down  in  the 
shape  of  a  snow-white  deposit  composed  chiefly  of  ammonio- 
magnesian  phosphate  and  amorphous  phosphate  of  lime.  If 
the  entire  fluid  present  a  milk-like  cloudy  appearance,  the 
alkaline  phosphates  may  be  considered  present  in  normal 
amount ;  if  it  is  denser,  more  cream-like,  there  is  an  increase. 
If,  on  the  other  hand,  the  fluid  is  but  slightly  cloudy,  trans- 
mitting light  distinctly,  the  phosphates  are  diminished. 

Nitrate  of  Silver   Test — A  solution   of  nitrate  of  silver 


100      PRACTICAL   EXAMINATION   OF   THE   URINE. 

added  to  urine  throws  down  a  yellow  precipitate  of  phosphate 
of  silver,  and  chloride  of  silver.  Both  are  soluble  in  ammonia, 
the  silver  phosphate  also  in  nitric  acid,  but  not  the  chloride. 
If,  therefore,  a  few  drops  of  ammonia  be  added,  they  will 
promptly  disappear.  If  now  nitric  acid,  just  sufficient  to 
neutralize  the  ammonia,  be  added,  the  precipitate  will  again 
reappear ;  but  the  moment  the  nitric  acid  is  present  in  ex- 
cess, the  silver  phosphate  is  redissolved,  but  the  chloride 
remains  in  suspension.  If  now  enough  ammonia  be  added 
again  to  neutralize  the  nitric  acid,  the  phosphate  of  silver 
will  again  fall ;  but  if  an  excess  be  added,  the  entire  preci- 
pitate, including  the  chlorides,  will  be  redissolved. 

Clinical  Significance The  alkaline  phosphates  in  the 

urine  are  influenced  chiefly  by  the  food,  whence  they  are 
mainly  derived  ;  phosphorus  is  also  oxidized  in  the  economy, 
and  a  small  part  of  the  phosphates  is  doubtless  derived  from 
the  disintegration  of  nervous  and  muscular  tissues.  Any 
increased  activity  of  vital  processes,  as  inflammations  and 
fevers,  would,  therefore,  favor  their  increase. 

Volumetric  Process  for  Phosphoric  Acid. 

This  process  is  based  upon  the  facts  that — 

1.  When  a  solution  of  phosphate  acidulated  with  acetic 
acid  is  treated  with  a  solution  of  nitrate  or  acetate  of  ura- 
nium, &  precipitate  falls  which  is  composed  of  uranium  phos- 
phate. 

2.  When  a  soluble  salt  of  uranium  is  added  to  a  solution 
of  potassium  ferrocyanide,  a  reddish-brown  precipitate  or 
color  is  developed. 

The  solutions  required  are — 

1.  A  standard  solution  of  sodium  phosphate,  made  by  dis- 


INORGANIC    CONSTITUENTS.  101 

solving  10.085  grammes  (155.60  grs.)  of  well-crystallized 
sodium  phosphate  (Nu2HPO4-f  12H2O)  in  distilled .  water, 
and  diluted  to  a  litre  (33.8  f  3)  ;  50  c.  c.  (13.5  f5)  then  con- 
tain .1  gramme  (1.54  grs.)  P2O5. 

2.  Saturated  solution  of  potassium  ferrocyanide. 

3.  Sodium    acetate    solution,    made    by   dissolving    100 
grammes  (1543  grains)  sodium  acetate  in  100  c.  c.  (27  f5) 
pure  acetic  acid,  and  diluting  with  distilled  water  to  1000 
c.c.  (33.8  f  3). 

4.  Solution  of  uranium  acetate,  such  that  1  c.  c.  will  cor- 
respond to  .005  gramme  or  5  milligrammes  phosphoric  acid. 

To  Prepare  the  Uranium  Acetic  Solution.  —  Dissolve  20.3 
grammes  (313.2  grs.)  of  yellow  uranic  oxide  in  strong  acetic 
acid  previously  diluted  with  distilled  water  to  nearly  a  litre. 
To  determine  the  strength  of  this  solution,  place  50  c.  c.  (13.5 
02.)  of  the  standard  solution  of  sodium  phosphate  in  a  beaker 
with  5  c.  c.  (1.35  f  3)  of  the  solution  of  sodium  acetate  and  heat 
in  a  water-bath  to  90°  to  100O  C.  (194C  to  212O  F.).  The  ura- 
nium solution  is  then  allowed  to  run  from  a  burette  into  the 
warm  mixture  until  precipitation  ceases.  Then  a  drop  of  the 
mixture  is  carried  by  a  glass  rod  into  contact  with  a  drop  of 
the  ferrocyanide  of  potassium  solution  on  a  white  plate,  or  to  a 
piece  of  the  filtering-paper  impregnated  with  it.  If  the  reddish- 
brown  of  the  uranium  ferrocyanide  does  not  appear,  continue 
the  cautious  addition  of  the  uranium  solution  until  the  color 
responds  to  the  test.  The  quantity  used  is  then  read  off,  being 
that  which  is  sufficient  to  decompose  sodium  phosphate  corre- 
sponding to  .1  gramme  (1.54  grs.)  of  P205,  whence  is  calculated 
the  amount  of  distilled  water  to  be  added  to  make  1  c.  c.  cor- 
respond to  .005  gramme  (.077  grain)  of  phosphoric  acid. 

Process Take   50  c.  c.  (13.5  f5)  of  urine;  add  5  c.c. 

(1.35  f3)  of  the  sodium  acetate  solution,  and  warm  in  a 

watcr-l);ith   as  above.     Fill  the  burette  with   the  uranium 

9* 


102      PEACTICAL   EXAMINATION"   OF   THE   URINE. 

solution,  and  drop  it  into  the  mixture  while  warm,  testing 
with  the  ferrocyanide  solution.  The  number  of  cubic  cen- 
timetres used  multiplied  by  .005  will  give  the  phosphoric 
acid  in  the  50  c.  c.  of  urine,  whence  calculate  the  quantity 
for  the  twenty -four  hours. 


XVII.  SULPHATES. 

The  sulphates  found  in  the  urine  are  those  of  soda  and 
potash,  the  former  preponderating.  The  quantity  in  twenty- 
four  hours  is  3  to  4  grammes  (46.29  to  61.72  grains)  cor- 
responding to  2  grammes  (30.86  grains)  sulphuric  acid. 

Detection  and  Approximate  Estimation This  is  simple 

with  any  of  the  barium  compounds  which  throw  down  a 
white  precipitate  of  barium  sulphate.  A  little  acid,  as  hydro- 
chloric, should  previously  be  added,  in  order  to  hold  in  solu- 
tion the  barium  phosphate,  which  is  otherwise  thrown  down, 
or  the  acid  may  be  previously  added  to  a  solution  of  barium 
chloride. 

If  to  a  small  quantity  of  urine  in  a  beaker-glass,  one-third 
as  much  of  the  acidulated  solution  of  barium  chloride  (1  part 
to  8  plus  ^  a  part  hydrochloric  acid)  is  added,  and  there 
occurs  an  opaque  milky  cloudiness,  the  proportion  of  sul- 
phates is  normal ;  if  the  opacity  is  intense,  and  the  whole 
mixture  has  the  appearance  and  consistence  of  cream,  the 
sulphates  are  increased  ;  if,  on  the  other  hand,  there  is  only 
a  slight  cloudiness,  so  that  light  is  still  transmitted,  the  sul- 
phates are  diminished. 

Clinical  Significance — -The  sulphates  are  derived  partly 
from  the  food  and  partly  from  the  tissues,  are  increased  by 
the  introduction  of  sulphur  compounds,  sulphuric  acid  and 
its  soluble  combinations,  by  an  animal  food,  and  by  any 


INORGANIC   CONSTITUENTS.  103 

causes  producing  increased  rapidity  of  tissue  change,  as 
active  exercise,  the  introduction  of  oxygen,  febrile  move- 
ments, and  fevers.  The  greatest  increase  has  been  observed 
in  meningitis,  cerebritis,  rheumatism,  and  affections  of  the 
muscular  system.  They  are  diminished  in  an  exclusively 
vegetable  diet. 

The  Volumetric  Process  for  Sulphuric  Acid. 

This  depends  upon  the  principle  that  a  solution  of  chloride 
of  barium  will  throw  down  a  precipitate  from  a  given  quan- 
tity of  urine,  so  long  as  any  sulphuric  acid  is  present ;  and 
further,  that  in  thus  treating  a  specimen  of  urine  acidulated 
with  HC1,  a  neutral  point  is  reached  at  which  the  filtrate 
will  show  a  slight  opacity  as  well  with  the  sulphuric  acid,  as 
with  the  barium  chloride  solution.  In  such  a  fluid  we  are 
to  suppose  potassium  chloride,  barium  chloride,  and  potas- 
sium sulphate,  balancing  each  other.  If  now  either  barium 
chloride  or  potassium  sulphate  are  added,  it  itself  is  decom- 
posed, and  barium  sulphate  precipitated. 

The  solutions  required  are — 

1.  Solution  of  barium  chloride  so  concentrated  that  1  c.c. 
will  precipitate    exactly  12.25  milligrammes  HaSO4,  or  10 
milligrames    SO3   prepared    by   dissolving    30.5    grammes 
(470.6  grs.)  dry  crystallized  chloride  of  barium,  and  diluting 
to  a  litre  (33.8  f£). 

2.  Solution    of  potassium    sulphate  such  that  1    c.  c.= 
12.25  milligrammes  H2SO4;  or  10  milligrammes  SO3  pre- 
pared by  dissolving  21.775  grammes  (336.03  grs.)  chemi- 
cally pure   powdered  potassium  sulphate,  dried  at  100°  C. 
(212°  F.),  and  diluting  to  a  litre  (33.8  fg). 

Process — Place  100  c.  c.  (27  f  3)  urine,  acidulated  with 


104      PRACTICAL   EXAMINATION   OF   THE   URINE. 

20  to  30  drops  hydrochloric  acid,  and  heat  it  in  a  water- 
bath.  When  boiling,  allow  5—8  c.  c.  of  the  barium  solution 
to  flow  in  from  a  burette.  Remove  the  heat  and  allow  the 
precipitate  to  subside.  If  the  fluid  becomes  rapidly  clear, 
allow  another  cubic  centimetre  or  two  of  the  barium  solution 
to  flow  in,  reapply  the  heat,  and  filter  10  to  12  drops  of  the 
urine  into  a  small  test-tube,  add  some  of  the  barium  solution, 
and  observe  whether  there  is  a  precipitate  or  not.  If  not, 
add  to  another  portion  a  few  drops  of  the  potassium  sulphate 
solution,  by  which  we  learn  whether  an  excess  of  the  barium 
solution  has  been  added  or  not.  If,  however,  the  barium 
solution  still  produces  a  precipitate  in  the  portion  removed 
for  testing,  the  latter  is  returned  to  the  beaker,  and  more 
solution  allowed  to  fall  in,  determining  the  quantity  some- 
what by  the  intensity  of  the  reaction  in  the  test-tube,  and 
the  process  repeated  until  no  precipitation  takes  place  with 
the  barium,  and  until  a  slight  cloudiness  takes  place  when 
adding  the  potassium  sulphate  to  a  portion  of  the  filtered 
mixture.  If  the  latter  is  an  intense  reaction,  say  at  12  c.  c., 
then  we  know  that  the  correct  point  is  somewhere  between 
11  and  12,  and  the  process  is  repeated  as  far  as  11  c.  c., 
when  it  is  continued  very  cautiously,  adding  only  fractions — 
T^ths  of  a  centimetre — until  the  right  point  is  reached, 
whence  the  calculation  is  made  as  before. 


URINARY    DEPOSITS.  105 


URINARY  DEPOSITS. 

IT  has  already  been  said  that  strictly  normal  freshly 
passed  urine,  of  acid  reaction,  contains  no  sediment  what- 
ever, except  the  faint  flocculi  of  mucus  which  gradually 
subside  towards  the  bottom,  and  entangle  a  few  mucus- 
corpuscles  and  an  occasional  epithelial  cell.  Should  the 
urine,  however,  be  alkaline,  as  is  frequently  the  case  three 
to  four  hours  after  a  meal,  it  may  be  more  or  less  cloudy 
at  the  moment  it  is  passed,  and  quickly  deposit  a  flocculent 
precipitate  of  earthy  phosphates,  which  may  occupy  con- 
siderable bulk.  They  will  be  found  by  microscopic  exami- 
nation to  be  made  up  of  amorphous  granules,  and  will 
quickly  disappear  on  the  addition  of  a  few  drops  of  any 
acid. 

But  even  urine  which  is  strictly  normal  will,  in  the  course 
of  time,  form  deposits  as  the  result  of  different  reactions. 
These  deposits  differ  with  the  stages  of  such  reaction,  and 
should  be  perfectly  understood  by  the  student  before  he  is 
ready  to  interpret  any  sediment  arising  from  other  causes. 

1.  After  normal  urine,  completely  without  sediment,  has 
stood  for  a  time,  especially  at  a  moderate  temperature,  there 
is  often  observed  a  precipitate  of  amorphous  granular  mat- 
ter, readily  soluble  by  heat,  which  is  made  up  of  acid  urates 
of  potash,  soda,  and  ammonia,  with  which  urates  of  lime 
and  magnesia  are  occasionally  commingled.  (See  lower 
portion  of  Fig.  10.)  A  little  later  they  are  replaced  by 
rhombic  crystals  of  uric  acid,  stained  yellowish  or  yellowish- 


106      PRACTICAL   EXAMINATION   OF   THE    URINE. 

red.  These  are  often  associated  with  octahedral  crystals  of 
the  oxalate  of  lime. 

The  explanation  given  by  Scherer  of  the  occurrence  of 
these  deposits,  is  that  of  the  so-called  acid  fermentation,  in 
which,  through  the  agency  of  the  mucus  of  the  bladder, 
acting  as  a  ferment,  are  formed  lactic  and  acetic  acids  out 
the  coloring  matters.  These  take  away  a  part  of  the  base 
from  the  neutral  or  alkaline  urates,  and  produce  first  the 
more  insoluble  acid  urates  named  above,  which  are  de- 
posited ;  later  they  combine  with  the  remainder  of  the  base 
also,  and  leave  the  crystalline  uric  acid  sediment. 

As  though  favoring  this  so-called  acid  fermentation,  there 
are  also  often  found  at  this  stage  in  urine,  spores  of  torula 
cerevisece — the  yeast  fungus — small,  oval,  transparent,  struc- 
tureless cells,  to  be  again  referred  to.  Further,  sufficient 
proof  that  such  fermentation  takes  place  is,  however, 
wanting. 

A  much  more  satisfactory  explanation  of  the  occurrence 
of  these  deposits,  has  been  offered  by  Voit  and  Hoffman,* 
who  attribute  the  decomposition  of  the  basic  urates  to  the 
acid  phosphate  of  soda,  the  excess  of  phosphoric  acid  playing 
the  part  of  the  acetic  and  lactic  acid  in  the  fermentation 
theory,  and  decomposing  the  alkaline  urates  in  the  same 
way  and  with  the  same  results.  They  prove  their  position 
by  an  artificial  production  of  the  same  results,  by  adding  a 
solution  of  acid  phosphate  of  soda  to  a  solution  of  basic 
urates.  The  extent  to  which  the  reaction  goes  will  depend 
upon  the  quantity  of  acid  phosphate  of  soda  present,  and 
the  length  of  time  which  has  been  permitted  for  the  reaction 
to  take  place.  It  is  possible  also  for  the  latter  to  begin  at 

*  Neubauer  and  Vogel,  Analyse  des  Hams,  vi  Aufl.,  1872,  p. 
113,  from  Zeitschrift  fur  Analyt.  Chemie,  Bd.  7,  p.  397. 


URINARY    DEPOSITS.  107 

the  moment  of  secretion,  and  to  continue  in  the  bladder, 
causing  deposits  of  acid  urates  and  uric  acid  to  appear  as 
"  gravel"  or  "  sand"  immediately  after  the  urine  is  passed. 
Such  a  condition  would  be  pathological.  According  to  these 
authors,  a  more  rapid  action  of  the  acid  sodium  phosphate 
produces  an  amorphous  precipitate,  and  a  slower  separates 
the  crystalline  uric  acid.  The  more  rapid  reaction  may  be 
induced  by  a  more  abundant  separation  of  the  acid  sodium 
phosphate  or  a  greater  concentration  of  the  urine. 

In  the  course  of  these  changes,  also,  the  acidity  of  the 
urine  is  diminished,  and  it  may  become  neutral  and  even 
alkaline  before  the  phenomena  of  the  next  stage  to  be  de- 
scribed— the  alkaline  fermentation — set  in. 

2.  After  a  still  longer  but  variable  period,  which  is  shorter 
in  warm  weather  and  longer  in  cold,  we  have  the  so-called 
alkaline  fermentation,  which  is  a  real  fermentation.-  This, 
in  which  decomposing  mucus  is  also  thought  by  some  to  be 
the  ferment,  is  ascribed  by  Tieghem*  to  the  action  of  a  little 
torula,  structureless,  and  without  a  cell-wall,  which  multi- 
plies by  budding,  not  at  the  surface  but  within  the  urine  or 
at  the  bottom  of  the  vessel,  where  it  with  the  deposited  salts 
forms  a  white  sediment.  In  this  fermentation  we  have  the 
urea  converted  into  carbonate  of  ammonia,  as  already  ex- 
plained, by  the  addition  of  two  equivalents  of  water.f  As 

*  Neubauer  and  Vogel,  Analyse  des  Harns,  vi  Auflage,  1872,  pp. 
110  and  130. 

f  An  explanation  of  the  delay  which  sometimes  occurs  in  the 
appearance  of  these  phenomena  is  based  on  the  recognition  of  the 
multiplication  of  these  spores  as  the  cause  of  the  fermentation.  If 
infusoria  are  simultaneously  developed,  the  urea  is  more  slowly 
converted,  and  if  the  surface  of  the  urine  happens  to  be  covered 
with  other  plant  vegetation,  as  is  sometimes  the  case  (mildew),  the 


108      PRACTICAL   EXAMINATION    OF   THE   URINE. 

the  result  of  this  conversion,  the  urine  is  rendered  highly 
alkaline,  and  a  further  change  in  the  character  of  the  sedi- 
ment takes  place.  At  the  very  beginning  of  the  reaction, 
when  the  urine  may  still  be  neutral  or  even  weakly  alkaline, 
the  uric-acid  crystals  begin  to  dissolve  and  to  change  their 


Prismatic  crystals  of  sodium  nratc,  spherules  of  ammonium  urate,  and  amor- 
phous urates,  with  octahedral  crystals  of  oxalate  of  lime.  (Ranke.) 

form  so  as  to  become  more  or  less  unrecognizable,  while  on 
their  fragments  may  often  be  seen  to  adhere  prismatic  crys- 
tals of  urate  of  soda  and  dark  spheres  of  urate  of  ammonia. 
(Fig.  10.)  As  the  reaction  becomes  alkaline,  the  uric  acid 

urine  may  remain  acid  for  months  in  consequence  of  the  interfer- 
ence with  the  access  of  oxygen,  on  the  presence  of  which  the  spore 
is  dependent  for  its  growth  and  multiplication. 


URINARY    DEPOSITS. 


109 


altogether  disappears,  and  the  field  becomes  crowded  with 
granules  of  amorphous  phosphate  of  lime,  beautiful  triangu- 
lar prisms  ("  coffin-lid"  shaped  crystals),  and  their  modifica- 
tions, of  the  triple  phosphate  of  ammonium  and  magnesium, 
and  opaque  black  balls  of  urate  of  ammonium  often  beset  with 
spiculae  (Fig.  11)  ;  the  spores  referred  to  are  also  often  pres- 


Spiculated  spherules  of  ammonium   urate  along  with  triple  (ammonio-magne- 
siuin)  phosphate  and  octahedral  crystals  of  the  oxalate  of  lime.  (Kauke.) 

ent,  while  millions  of  bacteria  vibrate  slowly  along,  or  form 
granular  aggregations  about  a  fragment  of  organic  matter, 
and  an  occasional  infusorium  darts  across  the  field  of  view 
with  magnified  celerity.  Commonly,  however,  the  inter- 
mediate stage  is  lost  sight  of,  and  the  stage  just  described  is 
the  only  one  seen  in  the  alkaline  fermentation.  Such  urine 
has  an  ammoniacal  and  putrescent  odor,  is  cloudy  from  the 
suspended  phosphate  of  lime  and  bacteria,  and  exhibits  to 
the  naked  eye  an  abundant  white  deposit. 
10 


110      PRACTICAL  EXAMINATION   OF   THE   UWNE. 

Either  of  the  above  set  of  changes  may  take  place  within 
the  economy,  in  the  pelvis  of  the  kidney  or  in  the  bladder, 
and  as  such  become  pathological  states  which  are  constantly 
met  with  in  practice,  the  first  in  the  condition  of  uric  acid 
gravel  or  calculus  with  its  incident  suffering,  and  the  second 
in  the  phenomena  of  irritation  and  inflammation,  more  par- 
ticularly of  the  bladder,  due  to  obstruction  by  stone,  stricture 
or  malignant  disease.  It  also  seems  to  be  a  matter  of  modern 
observation  that  the  germs  of  the  fungi  above  alluded  to, 
which  seem  to  have  a  very  close  relation  to  the  phenomena 
described,  either  as  cause  or  effect,  may  be  introduced  from 
without  by  the  use  of  imperfectly  cleansed  catheters,  sounds 
or  similar  instruments. 

With  this  preliminary  knowledge  of  the  rationale  of  the 
causation  of  a  large  proportion  of  urinary  deposits,  we  are 
ready  to  take  up  their  detailed  consideration,  previous  to 
which,  however,  allusion  must  be  made  to 

Extraneous  Substances  found  in  Urine These  are  very 

various,  and  include  indeed  all  substances  which  are  liable 
to  get  into  vessels  containing  urine.  The  most  common 
among  these  are  fibres  of  cotton  and  linen,  hair  of  blankets, 
worsted,  wool,  human  hair,  cats'  hair,  splinters  of  wood,  oil 
globules,  starch  corpuscles,  tea-leaves,  bread  crumbs,  etc. 
With  the  microscopical  appearances  of  all  these  the  student 
should  familiarize  himself  before  he  begins  the  examination 
of  urinary  sediments. 

Scratches  and  marks  in  the  glass  slides  may  also  confuse, 
if  not  mislead,  the  beginner,  and,  if  they  become  filled  with 
coloring  matters,  are  more  likely  to  do  so.  Such  error  was, 
for  a  long  time,  occasioned  by  the  pigmented  markings  often 
found  in  glass  slides,  which  were  so  long  and  so  often  described 
by  observers  as  pigment  flakes.  They  are  little  depressions 


*  % 


mssamm  tmmmm  ®ma& 
©a<i 


URIXARY    DEPOSITS.  Ill 

or  scratches  in  the  glass  which  have  become  filled  with  oxide 
of  iron  used  in  the  polishing  of  the  glass,  and  can  be  better 
appreciated  by  a  study  of  the  annexed  plate  than  by  any 
description.  Their  true  character  was  first  pointed  out  by 
Dr.  J.  G.  Richardson,  of  this  city. 

CLASSIFICATION  OF  URINARY  DEPOSITS. 

Efforts  have  been  made  to  classify  sediments  on  different 
bases,  that  is,  on  the  ground  of  their  external  naked-eye 
characters  as  to  balk,  color,  weight,  etc.,  again  with  regard 
to  their  nature  and  origin,  whether  organized  or  unorgan- 
ized, crystalline  or  amorphous,  and  finally  as  to  the  reaction 
of  the  urine  in  which  they  are  found. 

The  simplest  division  is  into  unorganized  and  organized. 
A  further  division  of  these  groups  into  crystalline  and  amor- 
phous seems  to  separate  groups  which  are  naturally  associated, 
and  is  therefore  omitted. 

UNORGANIZED. 

I.  Uric  acid  (crystalline). 

«.  Acid  sodium  urate  (amorphous,  oc- 
casionally crystalline). 

b.  Acid  potassium  urate  (amorphous). 

c.  Acid  calcium  urate  (amorphous). 

d.  Acid  ammonium  urate  (crystalline). 
III.  Oxalate  of  lime  (crystalline). 

a.  Ammonio-magnesian  phosphate 
(crystalline). 


II.    Uric  acid  com- 


IV.  Earthy  phosphates. 


b.  Calcium  phosphate  (amorphous 


and  crystalline). 
V.  Carbonate  of  lime  (crystalline). 
.    VI.  Leucin  and  tyrosin  (crystalline). 
VII.  Cystin  (crystalline). 


112      PKACTICAL   EXAMINATION    OF   THE   URINE. 


ORGANIZED. 

I.  Mucus  and  pus.  V.  Spermatozoids. 

II.  Epithelium.  VI.  Fungi  and  infusoria. 

III.  Blood.        „  VII.  Elements  of  morbid  growths. 

IV.  Casts.  VIII.  Entozoa. 


I.    UNORGANIZED  SEDIMENTS. 

I.  URIC  ACID.  Occurrence,  etc Uric  acid  presents 

itself  as  a  sediment  of  small  bulk,  sinking  to  the  bottom, 
but  sometimes  adhering  also  to  the  sides  of  the  glass.  The 
individual  crystals  are  often  large  enough  to  be  seen  by  the 
naked  eye,  and  in  their  aggregation  often  form  masses  so 
large  as  to  be  characterized  by  the  terms  u  sand,"  "  gravel," 
"  red-pepper  grains."  This  latter  term  is  based  upon  the 
red  or  yellowish-red  coloration  which  uric  acid  crystals  in 
urine  exhibit. 

They  are  found  perfect  only  in  acid  urine,  often  at  the 
end  of  the  so-called  acid  fermentation,  in  urine  concentrated 
from  any  cause,  and  where  there  is  a  pathological  increase 
in  the  production  of  uric  acid  due  to  imperfect  oxidation  or 
assimilation. 

Recognition The  typical  shapes  of  a  uric  acid  crystal 

may  be  said  to  be  a,  four-sided  rhomb  and  six-sided  plate. 

But  it  is  comparatively  seldom  that  the  typical  forms  are 
observed,  the  latter  shape  being  somewhat  rare,  and  the 
angles  of  the  former  being  generally  so  rounded  off  that  the 
crystal  assumes  an  ovoid  or  "  whetstone"  shape,  of  very  dif- 
ferent, sizes,  some  being  mere  points  with  powers  of  200  to 
300  diameters,  while  others  are  large  enough  to  be  seen  by 
the  naked  eye.  Further  shapes  are  those  of  sections  of  a 
barrel,  envelope,  spear,  fan,  of  a  comb  with  teeth  on  two 


URIXARY    DEPOSITS. 


113 


sides,  quadrilateral  prisms  with  terminal  planes,  dumb-bells, 
and  even  other  forms.  What  are  commonly  called  "  dumb- 
bells" of  uric  acid  may  be  rather  compared  to  a  tuft  of  hay 

FIQ.  12.    (After  Harley.) 


constricted  at  its  middle.  These  varied  forms  practice  soon 
teaches  one  to  recognize,  even  though  they  may  deviate 
much  from  the  typical  shape.  Uric  acid  crystals,  as  ob- 
served, are  almost  invariably  colored,  and  can  generally 
thus  be  distinguished  from  other  deposits.  Dr.  Beale* 
states  that  two  or  three  instances  have  come  under  his 
notice  in  which  they  were  not  colored.  Uric  acid  crystals 
are  met  singly,  but  very  commonly  they  are  aggregated, 


Kidney  Diseases  and  Urinary  Deposits,  Philadelphia,  1869,  p. 


371. 


10* 


114      PRACTICAL   EXAMINATION   OF   THE   URINE. 

forming  beautiful  rosettes  and  other  shapes  of  aggregation  of 
such  size  as  to  be  easily  visible  to  the  naked  eye — as  the 
"  red-pepper  grains"  already  alluded  to — and  to  give  pain 
in  their  transit  through  the  ureter. 

FIQ.  13.     (After  Harley.) 


re  unusual  forms  of  uric  acid  crystals. 


Fig.  12  exhibits  the  more  usual  varieties  of  uric  acid,  and 
Fig.  13  some  of  the  rarer  forms. 

Tests  for  Uric  Acid. — Whenever  a  crystalline  deposit  is 
of  doubtful  character  and  suspected  to  be  uric  acid,  if  the 
latter,  it  will  respond  as  follows  : — 

1.  Insoluble  in  cold  or  hot  water,  it  will  readily  dissolve 
in  the  alkalies,  soda,  potash,  or  ammonia.  If  then  the  alka- 
line solution  be  treated  with  an  excess  of  acetic  acid,  in  a 
few  hours  typical  whetstone-shaped  forms  will  crystallize 
out. 


URINARY    DEPOSITS.  115 

2.  Or  the  sediment  may  be  placed  on  a  glass  slide,  and 
treated  with  the  murexid  test,  as  described  on  page  91. 

The  dumb-bell  crystals  of  uric  acid  occasionally  met  with 
may  be  distinguished  from  the  dumb-bell  crystals  of  the  oxa- 
late  of  lime,  by  the  characteristic  shape  already  referred  to, 
by  their  larger  size,  their  darker  color,  and  their  solubility 
in  alkalies. 

II.  URIC  ACID  COMPOUNDS — (a)  Sodium  urate,  mainly 
amorphous,  is  sometimes  crystalline.  It  always  forms  a 
part,  and,  according  to  Bence  Jones,  a  predominant  part  in 
the  pulverulent,  heavy,  variously  tinted,  and  generally  bulky 
deposit  of  the  mixed  urates  known  as  "  brick-dust"  or 
"  lateritious"  sediment.  The  degree  of  coloration  of  this 
sediment  depends  upon  that  of  the  coloration  of  the  urine 
whence  it  falls.  From  pale  urine  of  low  specific  gravity, 
1010  to  1014,  an  almost  white  sediment  separates,  falling 
very  slowly,  and  producing  therefore  an  opaque  cloudy 
appearance  in  suspension,  but  readily  disappearing  on  the 
application  of  heat ;  from  urine  of  an  amber  color,  and  spe- 
cific gravity  of  about  1018,  the  urates  deposited  are  fawn- 
colored  ;  and  from  high-colored  urine  of  higher  specific 
gravity,  we  have  the  true  red  "  brick-dust"  sediment.  The 
sediment  is  found  in  acid  urine,  or  urine  in  which  the  acid 
fermentation  has  only  commenced,  and  has  not  been  ope- 
rating so  long  as  completely  to  remove  the  base  and  cause 
the  crystalline  uric  acid  to  be  deposited.  It  is  found  also  in 
urine  concentrated  from  any  cause,  or  where  it  has  cooled 
down  considerably  below  37°  C.  (98^°  F.),  or  where  there 
is  defective  oxidation  or  assimilation,  as  in  fevers. 

Recognition — By  far  most  frequently  do  we  find  sodium 
unite  in  fine  amorphous  granules,  by  their  shape  in  no  wise 
distinguishable  from  other  fine  granular  matters,  requiring, 


116      PRACTICAL   EXAMINATION    OF   THE   URINE. 

therefore,  the  chemical  tests  for  their  discrimination.  The 
adhesion  of  these  fine  granules  to  partially  coagulated  shreds 
of  mucus  sometimes  gives  rise  to  an  appearance  resembling 
finely  granular  casts  (see  Fig.  10),  which  is  readily  detected 
by  the  experienced,  but  which  may  mislead  the  beginner. 
The  careful  application  of  heat,  or  the  addition  of  a  drop  of 
acetic  acid,  will  promptly  dissipate  the  illusion.  These 
granules  of  sodium  urate  also  assume  a  larger  size,  and 
become  little  spherules  sometimes  provided  with  spicules 
(see  Fig.  14),  which  are  considered  by  some  (G.  Bird, 
Beale)  to  be  spicules  of  uric  acid.  (See  Fig.  14,  from  Beale, 
Kidney  Diseases.)  Other  spherules  are  provided  with  pro- 


Spherules  and  spiculated  spherules  of  urate  of  ammonium  (sodium?)  ;  amor- 
phous granular  unites. 

jecting  and  curved  processes,  and  are  believed  by  Hassall 
(2d  edition,  page  75),  and  Thudicum  (2d  edition,  page  81)  to 
be  composed  of  sodium  urate  throughout.  That  the  spines 
were  also  urate  of  sodium,  Thudicum  considered  evidenced 
by  their  solubility  in  water.  A  modified  form  of  the  latter 
is  probably  the  irregularly  star-shaped  crystals  in  Dr.  Beale's 
Fig.  110,  from  the  urine  of  a  patient  suffering  with  perito- 
nitis. But  all  of  these  forms  of  spherules  with  straight  and 
incurved  processes  (thorn-apple  shapes)  are  put  down  by  the 
German  observers  (Neubauer  and  Vogel,  Hoffmann  and 


URINARY    DEPOSITS.  117 

Ultzmann)  as  crystalline  forms  of  urate  of  ammonium,  in 
which  I  am  inclined  to  concur,  at  least  with  regard  to  those 
which  are  found  at  the  stage  of  reaction  intermediate  be- 
tween the  acid  and  alkaline  fermentations,  or,  perhaps, 
rather  at  the  beginning  of  the  latter,  when  ammonia  makes 
its  appearance,  and  is  accompanied  by  the  ammonio-magne- 
sian  phosphate.  But  any  spherules  which  occur  early  in 
the  acid  reaction,  or  before  it  is  possible  for  any  ammonia  to 
be  present,  are  probably  sodium  urate. 

The  sodium  urate  is  also  rarely  found  in  dumb-bells  which 
are  also  striated  and  broad  at  the  extremities  like  those  of 
uric  acid,  but  less  disposed  than  the  latter  to  break  up  at  the 
extremities  into  individual  acicles  (Atlas  of  Hoffmann  and 
Ultzmanri,  Taf.  IX.).  One  half  of  one  of  these  dumb-bells, 
viewed  from  above,  would  be  fan-shaped. 

Under  the  same  circumstances,  at  the  end  of  the  acid,  and 
at  the  beginning  of  the  alkaline  fermentation,  do  we  also 
have  the  true  prismatic  crystals  of  acid  sodium  urate, 
arranged  in  star-like  masses  (Fig.  15,  p.  118). 

(b)  Acid  potassium  urate  is  also  amorphous,  very  soluble, 
and  occurs  under  the  same  circumstances  as  sodium  urate,  as 
a  constituent  of  the  mixed  urates. 

(c)  Acid  calcium  urate  occurs  very  seldom  and  in  small 
quantity,  of  white  amorphous  powder,  along  with  tfhe  mixed 
urfttes.     It  is  with  difficulty  soluble  in  water,  and  known  to 
have  lime  for  its  base,  by  leaving  a  residue  of  calcium  car- 
bonate after  incineration. 

(d)  Acid  Ammonium  Urate.    Occurrence — This  is  found 
along  with  amorphous  earthy  phosphates  and  crystals  of  the 
triple  phosphates  of  ammonia  and  magnesia,  in  urine  in  which 
the  alkaline  fermentation  has  commenced.     It  is  the  only 
urate  found  in  alkaline  urine. 


118      PRACTICAL   EXAMINATION   OF   THE   URINE. 

Recognition — It  is  crystalline,  and  presents  itself  in  the 
shape  of  smooth  and  characteristic  "  thorn-apple"  spherules 
(Figs.  14  and  15),  which  serve  easily  to  distinguish  them. 
They  are  dissolved  in  hot  water,  and  dissolve  with  the  evo- 
lution of  uric  acid  crystals,  by  hydrochloric  or  other  acid. 
Liquor  potassa,  added  to  them,  evolves  the  odor  of  ammonia, 
and  they  give  the  murexid  reaction  with  nitric  acid  and 
ammonia. 


Prismatic  crystals  of  sodium  urate,  spherules  of  ammonium  urate  and  amor- 
phous urates  with  octahedral  crystals  of  oxalate  of  lime.     (Ranke.) 

Tests. — Though  the  acid  urates  are  much  more  insoluble 
than  the  neutral  urates  remaining  in  solution,  requiring  124 
parts  of  boiling  water,  and  1150  of  cold,  they  readily  dis- 
solve on  the  application  of  heat  to  the  slide  or  test-tube  con- 
taining them.  They  are  dissolved  also  by  the  alkalies, 


URINARY   DEPOSITS.  119 

liquor  potassa,  or  soda.  Treated  with  nitric,  hydrochloric, 
or  acetic  acids  (the  diluted  are  better  on  account  of  their 
slower  action),  they  dissolve  with  the  subsequent  crystalli- 
zation of  uric  acid.  They  also  respond  to  the  murexid  test. 

III.  OXALATE  OF  LIME.  Occurrence The  oxalate  of 

lime  crystals  are  most  frequently  met  in  acid  urine,  often 
therefore  alongsid^  of  crystals  of  uric  acid,  but  they  may  also 
be  met  in  alkaline  urine,  along  with  crystals  of  the  triple 
phosphate.  They  are  particularly  abundant  in  the  urine 
after  a  meal  of  rhubarb  plant,  after  the  use  of  tomatoes,  and 
other  vegetables  containing  oxalic  acid.  There  are  no 
means  by  which  the  presence  of  oxalate  of  lime  may  be  fore- 
told before  a  microscopic  examination  of  the  urine  is  made. 
The  first  edition  of  this  book  contained  the  following :  "It 
never  forms  a  deposit  appreciable  to  the  naked  eye,  and  most 
commonly  the  crystals  do  not  descend  to  the  bottom  of  the 
glass,  but  are  caught  as  it  were  by  the  flocculi  of  mucus 
which  float  towards  the  bottom,  rather  than  occupy  it."  Later 
and  repeated  observations  have  convinced  me  that  in  many 
instances  the  whole  of  this  cloud-like  mass,  so  much  resem- 
bling mucus,  is  made  up  of  oxalate  of  lime. 

Recognition — Two  forms  of  calcium  oxalate  crystals  are 
met,  the  octahedra  and  the  dumb-bell  crystals.  The  former 
appear  somewhat  differently  according  as  they  are  seen  in 
the  longer  diameter  or  in  the  shorter.  They  may  be  said  to 
be  made  up  of  two  four-sided  pyramids,  placed  base  to  base, 
and  when  viewed  in  the  longer  diameter,  may  readily  be 
detected  as  such  by  the  microscope.  When  seen  in  the  op- 
posite direction,  their  characteristic  appearance  is  that  of  a 
square,  crossed  obliquely  by  two  bright  lines,  and  if  the 
crystal  be  very  small,  it  will  appear  :  s  a  square  with  a  bright 
point  in  the  centre — a  characteristic  appearance  by  which 


120      PRACTICAL   EXAMINATION   OF   THE   URINE. 

one  may  soon  learn  to  detect  them,  even  when  they  are  very 
small.  They  are  often  seen  in  aggregations  of  three,  four, 
or  more,  closely  adherent,  and  forming  as  it  were  micro- 
scopic calculi. 

Fio.  16.     (After  Harley.) 


The  dumb-bells,  very  much  more  rarely  met  with,  are 
highly  characteristic,  and  although  we  have  spoken  of  dumb- 
bells of  uric  acid  and  of  ammonium  urate,  neither  of  the 
latter  present  the  typical  dumb-bell  appearance  like  those  of 
the  oxalate  of  lime.  To  these  are  found  also  allied  forms, 
circular  and  oval  shapes,  with  darker  or  brighter  centres, 
and  some  with  partial  concavities  at  the  sides,  as  though 
passing  over  into  dumb-bells.  Dumb-bells  are  also  met  with 
in  the  urine  aggregated,  forming  microscopic  calculi,  which 
go  far  to  explain  the  incipient  formation  of  calculi. 

Chemical  Characters The  form  of  crystals  of  oxalate  of 

lime  is  so  characteristic,  that  there  is  seldom  occasion  to 
make  use  of  chemical  tests  to  determine  them.  The  only 
crystals  which  at  all  resemble  them,  are  certain  forms  of  the 
triple  phosphate.  These  are  small  crystals,  modifications  of 
the  typical  triangular  prism,  with  its  bevelled  ends,  in  which 
the  body  of  the  prism  is  exceedingly  short,  as  if  it  were 


URINARY   DEPOSITS.  121 

almost  left  out,  so  that  the  two  inclined  triangular  ends 
closely  approach  each  other,  and  form  a  crystal  like  that  of 
the  octahedron  of  oxalate  of  lime.  Their  nature  may,  how- 
ever, be  suspected  by  the  character  of  the  larger  crystals 
around  them,  for  they  never  occur  alone.  Moreover,  they 
are  promptly  dissolved  by  the  addition  of  acetic  acid,  while 
the  oxalate  of  lime  is  totally  insoluble  in  this  acid.  The 
octahedra  are  highly  insoluble  in  water,  in  alkalies,  and  in 
the  vegetable  acids,  including  acetic,  but  are  soluble  in  the 
mineral  acids.  The  dumb-bells,  after  a  prolonged  action  in 
acetic  acid,  yield  their  crystalline  matter,  leaving  a  frame- 
work, which  maintains  the  original  shape  of  the  crystal. 
This  in  fact  explains,  perhaps,  the  shape  of  the  crystal.  It 
has  been  shown  by  Mr.  Rainey  and  others,  that  the  presence 
of  organic  matter,  as  mucus,  interferes  with  crystallization 
in  the  regular  manner.  The  dumb-bells  of  oxalate  of  lime 
can  readily  be  distinguished  from  the  dumb-bells  of  uric  acid 
or  urates  by  the  solubility  of  the  latter  in  alkalies. 

The  acid  phosphate  of  soda,  according  to  Neubauer,*  pos- 
sesses a  power  of  solution  over  the  oxatate  of  lime,  often 
holding  it  in  solution,  and  he  gives  a  method  by  which  the 
latter  may  be  obtained  from  solution  in  the  urine  by  its 
agency,  as  follows:  4  to  600  c.  c.  (108  to  162  f3)  of  the 
urine  to  be  tested  is  treated  with  solution  of  chloride  of  cal- 
cium, supersaturated  with  ammonia,  and  the  precipitate  dis- 
solved in  acetic  acid.  After  twenty -four  hours,  the  preci- 
pitate then  occurring,  which  nearly  always  contains  uric 
acid,  is  placed  on  a  filter,  washed  with  water,  and  a  few 
drops  of  hydrochloric  acid  poured  upon  it.  The  latter  dis- 
solves out  the  oxalate  of  lime  present,  and  leaves  the  uric 

*  Neubauer  and  Vogel,  op.  citat.  p.  174. 
11 


122      PRACTICAL   EXAMINATION   OF   THE   URINE. 

acid  on  the  filter.  The  filtrate  is  then  diluted  in  a  test-tube 
with  15  c.  c.  (2.83  f  3)  of  water,  and  overlaid  most  carefully, 
by  means  of  a  pipette,  with  very  dilute  ammonia  in  sufficient 
quantity.  At  rest,  the  two  fluids  gradually  mingle,  and  after 
twenty-four  hours  the  oxalate  of  lime  present  will  have  col- 
lected at  the  bottom,  and  octahedra  of  great  beauty  may  be 
studied  with  the  microscope. 

Neubauer  says  he  has  many  times,  in  this  manner,  ob- 
tained considerable  quantities  of  oxalate  of  lime,  where  there 
was  previously  no  deposit  whatever.  He  has,  however,  in 
other  instances  with  normal  urine,  obtained  negative  results, 
so  that  he  is  unable  to  decide  whether  oxalate  of  lime  should 
be  considered  a  normal  or  abnormal  constituent  of  urine. 

Sources  of  Oxalate  of  Lime  in  the  Urine — There  is  no 
doubt,  that  oxalic  acid  is,  at  times  at  least,  secreted  by 
the  kidneys,  and  meeting  immediately  the  lime  salts  for 
which  it  has  a  strong  affinity,  forms  the  crystals  we  are  con- 
sidering; for  both  octahedra  and  dumb-bells  are  not  infre- 
quently found  in  the  uriniferous  tubules  of  the  kidney,  and 
even  in  tube-casts.  Schunck  has  attempted  to  show  that 
the  oxalate  of  lime  is  formed  during  the  decomposition  of 
urine  from  the  oxalate  of  ammonium,  but  Neubauer  says  the 
oxalate  of  ammonium  is  converted  into  carbonate  of  ammo- 
nium. Others,  as  Owen  Rees,  Aldridge  of  Dublin,  Wb'hler, 
and  Frerichs,  allege  that  oxalate  of  lime  is  derived  from  a 
decomposition  of  uric  acid  and  urates.  Their  experiments 
would  seem  to  show  this,  and  it  is  undoubtedly  the  case  that 
deposits  of  oxalate  often  make  their  appearance  in  urine 
some  time  after  it  has  been  passed.  Two  sources  must, 
therefore,  be  admitted,  one  within  the  organism  and  one 
without. 

Clinical  Significance There  is  no  disease  with  which 


URINARY    DEPOSITS.  123 

tlie  oxalate  of  lime  is  particularly  associated,  nor  can  de- 
posits of  it  be  considered  indicative  of  derangement.  Abun- 
dant deposits  of  oxalate  of  lime  are  found  in  the  urine  of 
persons  who  are  typically  healthy.  On  the  other  hand,  it  is 
apt  to  occur  where  there  is  mal-assimilation,  and  hence 
dyspeptics  are  often  found  having  oxalates  in  their  urine,  as 
a  result  rather  than  a  cause  of  the  affection  from  which  they 
suffer. 

When  there  is  evidence  of  renal  calculi  in  descent  from 
the  pelvis  of  the  kidney,  and  oxalates  are  found  in  the  urine, 
especially  if  they  are  found  in  the  aggregations  referred  to, 
the  latter  may  afford  explanation  of  the  nature  of  the  stone. 
Unfortunately,  too  often  there  is  no  sediment  whatever  at- 
tending the  descent  of  a  calculus,  and  we  must,  therefore, 
determine  its  nature  without  such  aid,  or  remain  in  igno- 
rance. A  careful  examination  should,  however,  always  be 
made  of  the  urine  in  nephritic  colic,  as  valuable  information 
is  at  times  at  least  furnished  by  it,  especially  in  the  uric  acid 
lithiasis  where  uric  acid  sediment  is  often  found. 

IV.  EAHTIIY  PHOSPHATES.  Occurrence. — These  de- 
posits are  found  only  in  very  feebly  acid  or  alkaline  urine, 
and  are  the  more  abundant,  the  more  advanced  is  the  stage 
of  alkaline  fermentation.  They  appear  to  the  naked  eye  as 
bulky  opaque  white  deposits,  unless  they  are  accompanied 
by  blood,  which  then  more  or  less  tinges  them.  The  urine 
itself  is  apt  to  be  turbid  from  the  presence  of  amorphous 
phosphate  of  lime  in  suspension,  to  have  an  ammoniacal  and 
sometimes  a  fetid  odor,  though  not  necessarily.  They  are 
especially  abundant  in  the  urine  of  all  irritative  affections  of 
the  bladder,  and  often  attend  diseases  of  the  spinal  cord. 
The  earthy  phosphates  are  the  triple  phosphate  or  ammonio- 
magnesian  phosphate  and  the  phosphate  of  lime. 


124      PRACTICAL   EXAMINATION    OF   THE    URIXE. 

(u)  The  Ammonio-magncsian  Phosphate  (MgNH4PO4 
6H2O),or  triple  phosphate,  is  a  crystalline  deposit,  of  which 
the  typical  form  is  a  triangular  prism  (Fig.  17)  with  bevelled 
ends,  very  characteristic  and  easily  recognized. 

FIG  17.     (After  Harley.) 


In  addition  to  this,  there  is  an  infinite  variety  of  modifi- 
cations, with  one  or  more  corners  removed,  the  body  of  the 
crystals  variously  shortened,  etc.  Among  these  forms  are  the 
small  crystals  already  referred  to  as  being  possibly  mistaken 
for  the  oxalate  of  lime.  There  are  also  sometimes  found 
beautiful  star-shaped  (Fig.  18)  crystals  of  triple  phosphate, 
which  gradually  undergo  conversion  into  the  prisms,  and 
between  these  two  there  are  many  intermediate  forms. 

(b)  Phosphate  of  Lime,  amorphous  Ca3(PO4)2,  crystalline 
CalIPO4 — Phosphate  of  lime  is  most  frequently  found 
amorphous  under  the  same  circumstances  under  which  the 
triple  phosphate  is  found.  It  is,  however,  frequently  de- 


URINARY    DEPOSITS. 


125 


posited  from  normal  urine  in  which  it  is  held  in  solution 
during  the  acid  reaction  by  the  acid  phosphate  of  soda,  or 
carbonic  acid,  or  by  both.  At  any  rate  let  the  acid  reaction 
be  wanting,  as  it  is  three  or  four  hours  after  a  meal,  and  a 
copious  deposit  of  calcium  phosphate  often  takes  place,  which 
is  increased  by  boiling.  In  other  instances,  a  urine  may  be 
acid  in  its  reaction,  and  the  boiling,  apparently  by  driving 

Fia.  18.     (After  Harley.) 


off  the  carbonic  acid,  will  cause  the  phosphate  to  go  down. 
These  deposits  have  more  than  once  been  spoken  of  as  pos- 
sible sources  of  error  in  testing  for  albumen,  but  they 
promptly  disappear  on  the  addition  of  acids.  The  color  of 
the  phosphate  of  lime  alone  is  not  snow-white  as  that  of  the 
triple  phosphate,  but  rather  yellowish. 

Not  infrequently  we  meet  in  urinary  deposits  crystalline 
phosphate  of  lime  (Fig.  19),  which  occurs  sometimes  alone 
11* 


126      PRACTICAL   EXAMINATION   OF   THE    URINE. 

and  sometimes  along  with  the  triple  phosphate.  It  is  also 
met  in  urine  of  a  weak  acid  reaction,  but  strongly  disposed 
to  take  on  the  alkaline  fermentation.  The  occurrence  of 
crystalline  phosphate  of  lime  seems  peculiar  to  certain  indi- 
viduals, and  Hoffmann  and  Ultzmann  have  met  persons  per- 
fectly healthy,  who,  in  the  summer  months,  have  almost 
daily  deposits  of  crystalline  phosphate  of  lime.  They  are 
frequently  associated  with  octahedra  of  the  oxalate  of  lime. 


Crystalline  and  amorphous  phosph 


Recognition The  isolated  crystals  of  phosphate  of  lime 

may  be  said  to  be  wedge-shaped  or  even  conical,  from  which 
form  there  are,  however,  variations.  But  their  characteris- 
tic feature  is  in  their  arrangement,  which  is  that  of  a  circu- 


URINARY    DEPOSITS.  127 

lar  rosette,  in  which  the  apices  of  the  numerous  crystals 
forming  it  all  point  to  the  centre.  Phosphate  of  lime  is  also 
found  in  the  shape  of  spherules  or  even  dumb-bells.  The 
latter  are  said  by  Dr.  Beale  (Kidney  Diseases  and  Urinary 
Deposits,  p.  357)  to  be  deposited  in  decomposing  mucus,  not 
only  from  the  urinary  tract,  but  from  other  surfaces,  as  the 
gall-bladder.  Dr.  Beale  figures  such  dumb-bells  in  his  Plate 
xxi,  Figs.  116  and  118. 

Chemical  Characters — All  of  the  phosphates  are  dissolved 
by  acids,  but  are  insoluble  by  alkalies  and  heat,  whereas  the 
uric  acid  salts  are  dissolved  by  both  these  agencies.  The 
small  triple  phosphate  crystals,  which  resemble  those  of  oxa- 
late  of  lime,  dissolve  quickly  in  acetic  acid,  while  the  octa- 
hedra  are  untouched  by  it.  Uric  acid  itself  could  scarcely 
ever  be  confounded  with  phosphates,  occurring,  as  it  does, 
in  urine  of  different  reaction  ;  but  if  it  were  necessary  to 
discriminate  them,  the  former  are  dissolved  by  alkalies,  the 
latter  not.  Moreover,  the  murexid  test  will  not  respond  to 
phosphates,  but  will  to  uric  acid. 

V.  CARBONATE  OF  LIME  is  a  very  rare  deposit  in  human 
urine,  but  found  abundantly  in   horse's  urine.     When  pre- 
sent, it  occurs  in  small  spheres,  and  is  detected  by  its  effer- 
vescence with  acetic  acid. 

VI.  LEUCIN  AND  TYROSIN.     Occurrence — /These  crys- 
talline deposits  are  only  found  in  urine  which  is  loaded  with 
biliary  coloring  matters,  since  they  attend  only  grave  de- 
structive diseases  of  the  liver,  especially  acute  yellow  atrophy 
and  phosphorus  poisoning. 

Recognition. — If  suspected  in  urine  presenting  the  above 
characters,  it  may  be  slightly  evaporated,  when  the  crystals 
will  be  deposited  if  present. 

LEUCIN  presents  itself  in  the  shape  of  more  or  less  yellow- 


128      PRACTICAL   EXAMINATION   OF   THE   URINE. 

tinged,  highly  refracting  spheres,  which  may  at  first  sight 
be  taken  for  oil-drops.  A  little  study  will  show  them  re- 
fracting light  not  quite  so  strongly,  i.  e.,  not  possessing  quite 
so  wide  a  dark  border;  and  by  suitable  illumination,  many 
of  them  will  be  found  marked  with  radiating  and  concentric 
striae..  The  spherules  further  exhibit  a  peculiar  disposition 
to  aggregate,  appearing  partially  to  merge  where  two  edges 
come  together. 

Fio.  20. 


Leucin  spheres  and  tyrosin  needles. 

TYROS  IN  is  found  in  the  shape  of  very  fine  needles  ar- 
ranged in  tufts  or  "sheaf-like  collections,  often  crossing 
each  other  and  intersecting  at  their  constricted  central  por- 
tions (Fig.  20). 

Chemical  Characters. —  Leucin  spheres,  unlike  oil-glo- 
bules, are  insoluble  in  ether,  and  further  are  soluble  in 
caustic  alkalies,  but  not  in  cold  mineral  acids.  Tyrosin 
may  be  recognized  by  Hoffmann's  test.  A  suspected  de- 


UEINARY   DEPOSITS.  129 

posit  is  boiled  in  an  excess  of  water.  To  the  boiling  fluid  u 
few  drops  of  a  solution  of  mercuric  nitrate  are  added,  and 
there  asises  a  red  precipitate,  while  the  supernatant  fluid  is 
colored  red  to  purple-red. 

VII.  CYSTIX  (C3H7NSO2).  Occurrence  and  Recognition. 
— Cystin  is  a  rare  urinary  sediment.  Crystalline,  forming 
a  whitish  or  dirty  yellowish-gray  deposit,  which  on  micro- 
scopic examination  is  found  to  be  made  up  of  regular  six- 
sided  tablets  of  different  sizes,  often  so  arranged  that  one  of 
smaller  size  is  superimposed  on  one  of  larger,  and  this  upon 
a  still  larger,  and  so  on  ;  but  it  also  occurs  in  irregular 
masses  (Fig.  21).  It  is  usually  met  in  a  pale  urine,  both 
acid  and  alkaline,  developing  in  decomposition  the  odor  of 
sulphuretted  hydrogen,  as  well  as  that  of  ammonia,  the 
former  doubtless  derived  from  the  sulphur  contained  in  the 
cystin.  It  occurs  as  a  separate  urinary  deposit  as  well  as 
accompanying  cystin  calculus,  which  seems  sometimes  to  be 
hereditary. 

FIG.  21.     (After  Harley.) 


Chemical   Cliaracters It  is   soluble   in   ammonia,   and, 

upon  spontaneous  evaporation  of  the  ammoniacal  solution, 
the  six-sided  crystals  reappear,  showing  that  it  is  simply 
dissolved  in  the  ammonia,  and  not  in  chemical  combination 
with  it.  Now  if  the  six-sided  crystals  of  uric  acid,  which 


130      PRACTICAL   EXAMINATION   OF   THE    URIXE. 

so  closely  resemble  it,  and  which  often  accompany  it,  are 
dissolved  in  ammonia,  and  the  solution  allowed  to  evaporate, 
there  would  be  formed  ammonium  urate,  and,  on  evaporation 
of  the  solution,  this  ammonium  urate  would  remain  as  an 
amorphous  residue.  Cystin  is  also  insoluble  in  boiling 
water,  in  strong  acetic  and  very  weak  hydrochloric  acids ; 
but  it  is  readily  soluble  in  oxalic  and  strong  mineral  acids. 
It  is  soluble  in  potash,  and  insoluble  in  solution  of  carbonate 
of  ammonium,  and  therefore  may  be  precipitated  from  an 
acid  urine  by  the  alkaline  fermentation  ;  under  these  cir- 
cumstances it  would  be  accompanied  by  amorphous  phos- 
phate of  lime  and  crystalline  phosphate  of  ammonia  and 
magnesia,  with  neither  of  which  is  it  likely  to  be  confounded. 
In  a  mixed  deposit  containing  six-sided  crystals,  the  lime 
and  triple  phosphate  may  be  dissolved  out  with  acetic  acid, 
while  the  plates  of  cystin  will  remain.  They  may  then  be 
treated  with  ammonia,  as  above,  to  distinguish  them  from 
uric  acid. 

Cystin  contains  26  per  cent,  of  sulphur. 

ORGANIZED  DEPOSITS. 

I.  Mucus  AND  Pus Mucus,  even  if  present  in  consider- 
able amount,  could  not  be  recognized  by  its  own  properties, 
it  is  so  transparent  and  similar  to  urine  in  its  refractive  in- 
dex. It  is  visible  only  through  the  accidental  morphological 
constituents  which  it  more  or  less  constantly  holds  in  sus- 
pension. These  are  the  so-called  mucus-corpuscles  and 
epithelium  from  all  parts  of  the  genito-urinary  tract,  as  well 
as  crystals  of  the  oxalate  of  lime,  granules  of  sodium  urate, 
and  even  crystals  of  uric  acid.  In  strictly  normal  urine  the 
first  two  would  alone  be  present,  and  in  very  minute  quan- 


URINARY   DEPOSITS.  131 

tity.  These  cause  mucus  to  appear,  when  present  in  normal 
amount,  as  a  delicate  cloud,  often  barely  visible,  floating 
towards  the  bottom  rather  than  at  the  bottom  of  the  vessel. 

By  the  action  of  acetic  acid,  the  mucin,  an  element  of 
mucus  which  is  comparable  to  albumen,  though  not  coagu- 
lable  by  heat,  is  precipitated  in  the  shape  of  delicate  fibril- 
lated  bands,  which  are  sometimes  tortuous,  and  again  appear 
as  delicate  threads  known  as  mucin  threads.  If  a  little 
iodine  and  iodide  of  potassium  be  added  to  such  acetic  acid, 
they  are  made  even  more  distinct.  Tartaric  acid  and  very 
dilute  solutions  of  the  mineral  acids  have  the  same  effect, 
while  an  excess  of  the  same  will  redissolve  the  precipitate ; 
so,  too,  the  mineral  acids  will  dissolve  the  coagulum  of  acetic 
acid,  while  an  excess  of  the  latter  will  not  dissolve  it.  These 
coagula  may  sometimes  be  found  in  urine  to  which  no  acids 
have  been  added,  being  probably  produced  by  the  action  of 
the  acids  developed  in  the  acid  fermentation.  Under  these 
circumstances  they  are  particularly  apt  to  be  studded  with 
granular  urates,  which  may  cause  them  to  be  mistaken  for 
granular  tube-casts,  but  they  are  generally  very  much  nar- 
rower than  the  latter,  and  the  addition  of  a  little  warmth, 
hydrochloric  acid  or  alkali  will  quickly  dissolve  the  granules. 
(See  Fig.  10.) 

As  the  result  of  irritation  of  any  part  of  the  genito-urinary 
tract,  mucus  is  increased  in  quantity,  when  it  assumes  a 
thicker,  more  ropy  character,  and  becomes  more  or  less 
opaque,  but  even  here  the  opacity  is  due  to  the  increased' 
proportion  of  cellular  element  rather  than  to  the  mucus 
itself,  which  is  always  transparent.  Under  these  circum- 
stances, the  opaque  clouds  of  mucus  are  often  enormously 
increased,  and  with  them  the  adherent  epithelial  cells  from 
the  seat  of  irritation. "  When  thus  in  excess,  mucus  is  apt  to 


132      PRACTICAL   EXAMINATION   OF   THE   URINE. 

pervade  more  or  less  the  entire  mass  of  the  urine  rather  than 
sink  to  the  bottom,  giving  the  entire  fluid,  therefore,  a  glairy 
character.  Mucus,  however,  seldom  becomes  very  abundant 
without  being  attended  by  pus,  as  the  causes  producing  them 
are  but  differences  of  degree.  So  long,  however,  as  urine 
containing  mucus  is  without  albumen,  so  long  may  pus  be 
said  to  be  absent,  as  mucus  itself  contains  no  albumen, 
while  pus  does. 

The  Mucus-  and  Pus-corpuscle — The  mucus-corpuscle, 
as  it  appears  in  urine,  is  a  small,  granular,  spherical  or  nearly 
spherical  cell,  rather  larger  than  a  blood-corpuscle,  that  is, 
.008  to  .010  millimetre  (goVff  to  ssW  °f  an  incn)  in  dia- 
meter,  containing  one  or  more  nuclei.  In  a  healthy  con- 
dition of  mucous  membrane,  a  mucus- corpuscle,  however  it 
originates,  is  nothing  more  nor  less  than  a  young  epithelial 
cell  which  has  been  pushed  off  before  it  has  attained  the  cha- 
racters of  such  cell  in  its  development.  As  such,  therefore, 
we  must  not  too  closely  restrict  its  size,  for  who  shall  say 
where  the  mucus-corpuscle  terminates  and  where  the  epi- 
thelial cell  begins  ?  As  such  a  young  cell,  without  morbid 
impression,  simply  arrested  in  its  normal  development,  a 
single  nucleus  is  more  common  than  it  is  in  the  j9«s-corpuscle 
of  which  the  multiple  nucleus  may  be  said  to  be  more  cha- 
racteristic. But  here  the  difference  ceases.  For  the  pus- 
corpuscle,  when  young  (that  is,  not  the  subject  of  fatty 
degeneration),  is  a  cell  exhibiting  the  same  characters,  and 
may  be  defined  in  the  same  way.  The  fact  being  that  when 
a  cell  exhibiting  the  above  characters,  with  one  or  multiple 
nuclei,  is  found  upon  a  non-suppurating  surface,  it  is  called 
a  mucus-corpuscle,  while  the  same  cell  on  a  suppurating  sur- 
face would  be  called  a  pus-corpuscle.  Thus,  while  the  two 
are  physiologically  distinct,  they  are  anatomically  the  same, 


URINARY   DEPOSITS.  133 

the  physiological  difference  being  in  this,  that  a  pus-corpuscle 
is  a  cell  too  rapidly  produced  to  be  allowed  to  develop  into  the 
normal  tissue  of  the  part,  while  the  mucus-corpuscle  is,  as 
it  were,  only  accidentally  arrested  in  its  development.  The 
same  resemblance  which  exists  between  these  bodies  exists 
between  them  and  the  white  corpuscles  of  the  blood,  and  to 
the  whole  class  of  cells  to  which  the  term  leucocyte  or  white 
cell  is  conveniently  applied. 


Mucus-  and  pus-corpuscles  before  and  after  the  addition  of  acetic  acid. 

The  Action  of  Reagents. — The  mono-nucleated  mucus- 
corpuscle,  which  may  be  considered  an  older  mucus-corpuscle, 
or  young  epithelial  cell  thrown  off  at  a  later  period,  usually 
exhibits  its  single  nucleus  distinctly,  without  the  addition  of 
a  reagent ;  but  the  majority  of  leucocytes  have  not  their 
nuclei  visible  until  acted  upon  by  certain  reagents,  of  which 
two  acting  similarly  most  interest  us.  These  are  water  and 
dilute  acetic  acid. 

1.  Action  of  Water When  water  is  added  to  the  pus-  or 

mucus-corpuscle,  its  first  effect  is  to  cause  the  latter  to  swell 
up,  sometimes  to  twice  the  original  size,  next  to  become 
smooth,  the  granules  gradually  disappearing,  while  the  nuclei 
come  forth  with  great  distinctness.  Finally,  after  some  time 
the  body  of  the  cell  becomes  almost,  and  then  quite  invisible, 
while  the  nuclei  remain  some  time  longer.  The  circum- 
stances under  which  the  corpuscle  exists  in  urine  are  not 
12 


134      PRACTICAL   EXAMINATION   OF   THE   URINE. 

quite  identical,  because  in  it  we  have  a  solution  of  organic 
and  inorganic  matters  considerably  denser  than  water,  sp. 
gr.  1015  to  1025,  and  while  the  action  is  somewhat  similar, 
it  is  very  much  slower ;  and  if  the  specific  gravity  of  the 
urine  should  be  very  high,  exceeding  that  of  the  fluid  in  the 
cell,  there  might  be  no  effect,  or  a  contrary  one,  i.  e.,a  shrink- 
age of  the  cell  from  an  exosmosis  of  its  contents. 

2.  Acetic   Acid — The   action  of  dilute   (20   per   cent.) 
acetic  acid  is  identical  with  that  of  water,  except  that  it  is 
very  much  more  rapid,  and  the  stage  of  distinct   nuclei  is 
reached  much  sooner. 

3.  The  caustic  alkalies  have  a  rapidly  destructive  effect 
upon  these  corpuscles,  destroying  their  morphological  iden- 
tity, and  converting  them  into  a  gelatinous  adherent  mass. 

Characters  of  Urine  containing  Pus. — Urine  containing 
pus  deposits  an  opaque  white  sediment,  which  sinks  rapidly 
to  the  bottom,  so  long  as  the  reaction  is  acid  and  there  is  no 
mucus  present.  Such  urine,  when  shaken  up,  becomes  more 
or  less  opaque,  according  to  the  amount  of  pus  which  it  con- 
tains. The  opacity,  as  well  as  the  deposit,  often  resembles 
that  due  to  the  pale  granular  urates,  from  which  it  is  distin- 
guished by  the  disappearance  of  the  latter  on  the  application 
of  heat,  while  purulent  urine  deposits  albumen  under  the 
same  circumstances.  To  a  less  degree  does  urine  containing 
pus  resemble  that  containing  amorphous  phosphate  of  lime, 
but  the  latter  is  dissipated  by  acids,  while  acids  also  precipi- 
tate the  albumen  from  pus,  and  the  microscope  reveals  mil- 
lions of  the  granular  cells  already  described  as  pus-cells,  in 
many  of  which  the  nuclei  are  already  displayed  in  conse- 
quence of  the  action  of  water. 

Donne's  test  for  pus  is  based  upon  the  reaction  referred  to 
between  the  alkalies  and  pus.  It  consists  in  the  addition  of 


URINARY   DEPOSIT'S.  135 

liquor  potassa  to  the  deposit  of  pus  after  the  supernatant 
urine  is  poured  off.  If  the  deposit  is  pus,  it  is  promptly  con- 
verted into  a  viscid  gelatinous  substance  resembling  mucus, 
which  adheres  to  the  bottom  of  the  test-tube,  often  permitting 
its  inversion  without  falling  out,  and  which,  when  it  is  forced 
to  flow,  does  so  in  a  continuous  mass  as  the  albumen  runs 
out  of  a  broken  egg.  If  a  portion  of  this  glairy  mass  be 
examined  under  the  microscope,  the  pus-corpuscles  will  be 
found  to  have  be.en  destroyed,  or,  rather,  converted  into  the 
substance  itself.  If  the  action  has  not  been  very  long,  or 
the  proportion  of  alkali  to  the  pus  is  small,  the  nuclei  of  the 
corpuscles  may  still  be  found  as  black  dots  in  the  mass,  or  a 
certain  proportion  of  the  corpuscles  may  preserve  their 
integrity. 

Changes  in  Urine  containing  Pus — On  this  same  reaction 
is  based  a  most  important  change  which  urine  containing 
pus  undergoes  after  the  alkaline  fermentation  has  set  in. 
Through  the  agency  of  the  carbonate  of  ammonium  gene- 
rated, precisely  the  same  change  is  wrought,  and  the  urine 
contains  a  deposit  so  closely  adhering  to  the  bottom  of  the 
bottle  that  it  is  impossible  to  remove  it  with  a  pipette.  It 
must  be  remembered  that  this  is  not  muciis,  although  it  so 
closely  resembles  it,  and  although  microscopic  examination 
may  show  the  total  absence  of  pus-corpuscles.  These  have 
been  destroyed  by  the  alkali.  Care  should  be  taken,  there- 
fore, to  determine  the  reaction  of  the  urine  before  a  mucoid 
deposit  is  decided  upon,  and  if  it  is  alkaline,  another  of  acid 
reaction  should  be  obtained.  The  glairy  product  referred  to 
will  be  found  dotted  with  glistening  points,  which,  on  micro- 
scopic examination,  prove  to  be  crystals  of  triple  phosphate, 
while  the  supernatant  fluid  will  be  found  to  contain  albumen, 
which  is  wanting  in  deposits  of  pure  mucus. 


136      PKACTICAL   EXAMINATION   OF   THE   UEINE. 

Frequently,  in  diseases  of  the  bladder,  these  changes  take 
place  within  the  organ,  forming  a  gelatinous  mass,  which 
plugs  up  the  urethra  and  makes  it  almost  impossible  to  evacu- 
ate the  bladder,  thus  greatly  increasing  the  suffering  of  the 
patient.  In  such  cases,  the  only  remedy  is  to  wash  out  the 
bladder  with  weak  acid  solutions,  and  having  cleansed  it, 
keep  it  so  by  their  daily  use.  Even  when  acid  at  the 
time  of  being  passed,  these  urines  become  rapidly  alkaline 
afterwards. 

Sources  of  Pus  in  the  Urine — Pus  in  the  urine  may  come 
from  any  part  of  the  genito-urinary  tract.  When  descend- 
ing from  the  pelvis  of  the  kidney,  as  it  often  does,  in  im- 
pacted calculus,  it  is  less  apt  to  be  mingled  with  mucus,  the 
urine  retains  its  normal  reaction,  and  the  pus  is,  therefore, 
readily  miscible  with  the  urine,  and  as  promptly  deposited 
from  it.  When  coming  from  the  bladder,  if  the  urine  is  not 
already  alkaline,  it  is  apt  to  become  so  very  quickly,  and  we 
have  then  the  phenomena  described  as  incident  to  the  alka- 
line fermentation,  taking  place  soon  after  the  urine  is  passed, 
if  not  in  the  bladder  itself. 

In  diseases  of  the  prostate,  are  apt  to  be  found  long  plugs 
of  mucus,  which,  appearing  to  the  naked  eye  like  fine 
threads,  upon  microscopic  examination  are  found  made  up 
of  aggregated  pus-corpuscles,  in  which  are  sometimes  found 
the  larger  round  or  nearly  round  nucleated  cells  peculiar  to 
this  seat.  Similar  plugs  are  found  in  the  pus  from  gonor- 
rhoea, and  it  is  said  also  (Neubauer)  that  in  this  affection 
the  mucus-corpuscles  are  distinguished  from  those  derived 
from  the  bladder  by  their  larger  size,  their  "  glass-like  clear- 
ness," and  diminished  granulation.  If  there  be  no  gonor- 
rhoea, these  plugs  or  threads  point  almost  pathognomonically 
to  inflammation  or  irritation  of  the  prostate. 


URINARY    DEPOSITS.  137 

In  females,  pus  is  apt  to  obtain  in  the  urine  from  leucor- 
rhoca  or  other  purulent  discharge  from  the  vagina.  This 
should  not  be  forgotten. 

II.  EPITHELIUM — Epithelium  from  all  parts  of  the  genito- 
urinary tract  is  found  in  the  urine,  but  it  is  not  very  often 
that  we  are  enabled  to  locate  its  site  beyond  the  bladder  and 
vagina,  partly  because  of  the  comparatively  slight  differences 
in  the  epithelium  from  certain  locations,  and  partly  because 
maceration  in  the  urine  renders  such  feeble  distinctive  points 
even  less  marked. 

Three  varieties  of  epithelium  may,  however,  be  distin- 
guished in  urine,  with  tolerable  ease :  1st,  round  cells ;  2d, 
cylindrical  or  conical  and  spindle  cells ;  and,  3d,  squamous 
cells. 

(a)  Round  epithelial  cells  (a,  Fig.  23)  arise  from  the  urin- 
iferous  tubules,  particularly  in  their  convoluted  portion,  from 
the  deeper  layers  of  the  mucous  membrane  of  the  pelvis  of 
the  kidney,  of  the  bladder,  and  of  the  male  urethra.  Some 
of  these  cells,  originally  somewhat  flattened  by  pressure, 
swell  up  in  the  urine,  and  become  nearly  round.  They 
are  distinguished  from  pus-  and  mucus-corpuscles  by  their 
larger  size  and  their  single  nucleus,  which  is  distinct  with- 
out the  use  of  reagents,  while  the  multiple  nucleus  of  the 
pus-cell  requires  the  use  of  acetic  acid  to  exhibit  it.  There 
is  no  way  of  distinguishing  the  source  of  these  cells  more 
precisely  than  as  stated  above,  except  that  if  the  urine  be 
albuminous,  and  there  is  evidence  of  renal  disease,  it  may  be 
right  to  infer  them  to  come  from  the  tubules  of  the  kidney, 
or  from  the  pelvis  if  there  are  symptoms  of  impacted  calcu- 
lus ;  otherwise  from  the  urethra,  the  prostate,  Cowper's  or 
Littre's  glands,  but  cells  from  the  latter  are  rare.  If  the 
plugs  already  referred  to,  made  up  of  pus-cells  with  a  few 
12* 


138      PRACTICAL   EXAMINATION   OF   THE   URINE. 

larger,  nearly  round,  and  distinctly  mononucleated  cells  united 
by  mucus,  are  present,  we  may  infer  the  round  cells  to  be 
from  the  epithelium  of  the  prostate.  The  round  cells  from 
the  bladder  are  considerably  larger  than  those  from  other 
sources — twice  the  diameter  of  a  pus-cell. 


a,  round  epithelium  from  bladder. 

6,  columnar  epithelium  from  ureter  and  urethra. 

c1,  columnar  and  squamous  epithelium  from  deeper  layers  of  epithelium 

of  bladder. 
c2,  squamous  epithelium  from  superficial  layers  of  epithelium  of  vagina. 

(b)  Columnar  or  conical  and  spindle  cells  (i,  Fig.  23)  are 
derived,  the  first,  from  the  superficial  layers  of  the  pelves  of 
the  kidney,  from  the  ureters  and  urethra,  the  latter  from  the 
ureters  and  urethra. 

(c)  The  scaly  epithelial  cells  (c,  Fig.  23)  arise  from  the 
bladder  or  the  vagina.     These  are  flat,  but  often  thicker  at 


URINARY    DEPOSITS.  139 

the  middle,  contain  a  single  nucleus,  are  irregularly  polygo- 
nal in  outline,  and  often  folded  over  on  themselves  either 
completely  or  partially.  The  epithelial  cells  of  the  bladder 
(c1)  are  not  generally  as  large  as  those  of  the  vagina  (c2)  nor 
so  flat ;  they  are  less  apt  to  occur  in  layers  or  flakes,  although 
also  found  thus.  Frequently  it  is  not  safe  to  attempt  to  dis- 
tinguish between  the  two. 

In  acid  urine  these  cells  remain  a  considerable  length  of 
time,  but  in  alkaline  urine  they  are  gradually  destroyed,  be- 
coming at  first  swollen  and  more  transparent. 

III.  BLOOD-CORPUSCLES — These  get  into  the  urine  from 
the  tubules  of  the  kidneys,  from  the  pelvis,  the  bladder,  the 
prostate,  and  from  the  uterus  and  vagina  in  their  various 
physiological  and  pathological  hemorrhages.  They  may  be 
so  abundant  as  to  be  easily  distinguished  in  mass  by  the 
naked  eye,  or  they  may  require  the  microscope  for  their 
detection.  Urine  containing  blood  in  large  amount,  is  im- 
pressed with  the  red  color  of  the  latter,  but  containing  the 
moderate  amount  most  frequently  encountered  in  urine,  it 
obtains  a  color  depending  on  its  reaction.  If  the  urine  is 
acid,  it  assumes  a  peculiar  blackish-brown  color  which  has 
long  been  described  as  "  smoke-hued,"  and  which  is  so  char- 
acteristic as  to  enable  one  who  is  at  all  experienced,  to  de- 
cide at  once  as  to  the  presence  of  blood.  If,  on  the  other 
hand,  the  urine  is  alkaline  in  reaction,  it  assumes  the  bright 
red  color  of  blood.  Urine  containing  blood  in  any  quantity, 
appreciable  to  the  naked  eye,  is  albuminous. 

If  blood-corpuscles  are  present  in  numbers  sufficient  to 
produce  an  appreciable  deposit,  they  form  a  brownish-red 
pulverulent  mass  at  the  bottom  of  the  vial  if  they  come  from 
the  kidneys  or  ureters.  They  are  more  apt  to  be  found  in 
coagula,  if  they  come  from  the  bladder  or  urethra,  though 


140      PKACTICAL   EXAMINATION   OF   THE   URIXE. 

this  latter  is  not  necessarily  the  case ;  for,  on  the  other  hand, 
moulds  of  clotted  blood  are  sometimes  discharged  from  the 
ureters  with  all  the  agonies  of  nephritic  colic. 

Recognition. — Blood-corpuscles  are  recognized  under  the 
microscope  by  the  optical  properties  due  to  their  biconcave 
centres.  This  is  the  reversal  of  light  and  shadow  which 
they  undergo  in  focussing,  the  centre  and  periphery  alter- 
nating in  brightness  or  shadow,  as  the  object-glass  is  approxi- 
mated to  the  slide  or  removed  from  it.  This,  in  connection 
with  their  evident  biconcavity  when  seen  on  edge,  and  their 
yellowish  color,  will  always  serve  to  distinguish  them,  al- 
though the  effects  of  long-continued  maceration  tend  to  inter- 
fere in  different  degrees  with  the  distinctness  of  all  of  these 
features.  If  the  urine  is  a  dilute  one,  the  corpuscles  will 
swell  up,  become  biconvex  instead  of  biconcave,  finally 
spherical,  and  the  reversal  of  light  and  shadow  no  longer 
occurs,  while  the  coloring  matter  is  more  or  less  dissolved 
out.  Ultimately  the  corpuscle  altogether  disappears.  If,  on 
the  other  hand,  the  urine  is  highly  concentrated,  the  con- 
cavity becomes  more  marked  and  more  distinctive,  while  the 
corpuscle  itself  shrinks  and  becomes  smaller,  and  soon  ac- 
quires the  crenated  or  horse-chestnut-shape  (Fig.  24). 


In  an  acid  urine  the  blood-corpuscles  maintain  themselves 
for  a  long  time,  but  in  an  ammoniacal  urine  they  are  soon 


URIXAKY    DEPOSITS.  1.41 

dissolved,  being  soluble  in  alkalies.  The  haematocrystalline 
and  ha^matin  are  then  dissolved  in  the  urine,  and  may  be 
tested  for  as  already  directed. 

IV.  TUBE-CASTS — Tube-casts,  or  "  epithelial  cylinders" 
as  they  are  sometimes  called,  although  it  is  by  no  means 
certain  that  they  are  real  cylinders,  are  moulds  of  the 
uriniferous  tubules  produced  by  admission  into  the  latter,  by 
capillary  rupture  or  otherwise,  of  a  coagulable  constituent  of 
the  blood,  which  there  solidifies,  and  in  this  act  entangles 
whatever  it  may  have  surrounded  in  its  liquid  state ;  subse- 
quently it  contracts  and  slips  out  of  the  tubule  into  the 
pelvis  of  the  kidney,  whence  it  is  carried  to  the  bladder  and 
voided  with  the  urine. 

It  should  be  added,  however,  that  at  least  two  other 
views  as  to  the  mode  of  formation  of  casts  are  entertained, 
according  to  one  of  which  the  cast  is  a  result  of  the  disin- 
tegration and  fusion  of  the  epithelial  lining  of  the  tubules; 
and,  according  to  another,  of  a  secretion  from  these  same 
cells. 

The  mechanism  of  the  production,  on  the  supposition  of 
an  albuminoid  exudation  from  the  blood,  of  the  different  va- 
rieties of  casts  is  very  simple.  Thus,  suppose  a  tubule  to  be 
filled  with  detached  and  loosely  attached  epithelium  at  the 
time  the  fibrin  is  poured  into  it.  These  elements  are  entan- 
gled, and  as  the  cast  contracts,  carried  out  in  the  shape  of 
an  "  epithelial"  cast  (Fig.  25).  If  the  tubule  should  happen 
to  have  contained  blood,  the  cast  entangling  it  is  called  a 
"  blood-cast"  (Fig.  26).  Casts  containing  even  a  few 
blood-corpuscles  are  also  called  blood-casts.  The  basis  sub- 
stance of  blood-casts  is  most  probably  the  fibrin  of  the  blood. 
If  the  epithelium  be  firmly  attached  to  the  basement-mem- 
brane of  the  tube,  and  remain  behind  when  the  cast  passes 


142      PEACTICAL   EXAMINATION   OF   THE   UKINE. 

out,  or  if  the  tube  be  entirely  bereft  of  epithelium,  then  is 
the  cast  a  "  hyaline"  (Fig.  27),  or  structureless  east.     In 


Epithelial  casts  and  compound  granule-cells. 


the  former  instance  the  cast  is  of  smaller  diameter,  and  in 
the  latter  of  larger,  the  diameter  in  the  latter  being  that  of 


Fio.  26. 


Blood-casts  and  highly  granular  cells. 


the  former  plus  twice   the  thickness  of  an   epithelial  cell. 
Fig.  27,  from  Rindfleisch,  explains  this  sufficiently.     From 


URINARY   DEPOSITS. 


143 


causes  like  these,  as  well  as  a  subsequent  contraction  of  the 
cast  itself,  the  diameter  of  casts  may  vary  considerably, 
ranging  commonly  from  .01  to  .05  mm.  (^Vtf  to  5^  in.). 
A  cast  is  seldom  completely  hyaline,  generally  containing  a 
few  granules  and  one  or  two  glistening  oil-drops,  but  it  is 


V 

•aliue  and  granular  casts,  illustrating  the  formation  of  the  former  at  a. 


II  y 


still  called  hyaline.  Completely  hyaline  casts  do,  however, 
occur.  A  variety  of  hyaline  cast,  more  solid  in  appearance, 
and  resembling  molten  wax,  is  spoken  of  as  a  "  waxy  cast" 
(Fig.  28,  1).  Some  hyaline  casts  are  so  delicate  as  to  be 
overlooked,  unless  the  light  from  the  mirror  illuminating  the 
field  of  view  be  modified  by  shading  with  the  hand  or  by 
manipulation  of  the  mirror  itself.  If  a  cast  contains  granu- 
lar matter,  which  is  generally  the  granular  ddbris  of  a  de- 
generated epithelial  lining  of  a  tubule  or  of  blood-corpuscles, 
it  is  called  a  "  granular"  cast,  and  highly  granular  (Figs. 
2G  and  27),  moderately  granular  (Fig.  27,  b),  slightly  or 


144:      PRACTICAL   EXAMINATION   OF   THE   URINE. 

delicately   granular,  according  to  the  amount   of  granular 
matter  present.     When  the   material  of  granular   casts   is 

Fio.  28.     (After  Harley.) 


derived  from  broken-down  blood-corpuscles,  the  casts  appear 
yellow  or  yellowish-red.  Finally,  if  a  cast  is  loaded  with 
oil-drops,  either  free  or  contained  in  epithelial  cells,  it  is 
called  an  "  oil-cast"  or  fatty  cast  (Fig.  29). 

Casts  of  smaller  diameter  are  sometimes  found  within 
those  of  larger,  the  material  of  the  latter  having  been  poured 
out  around  that  of  the  former  after  it  has  undergone  some 
contraction.  This  occurs  usually  with  waxy  or  hyaline  casts. 
In  consequence  of  the  mode  of  formation  above  referred  to, 
hyaline  and  waxy  casts  vary  considerably  in  diameter,  some 
being  as  narrow  as  .025  millimetre  (T^V(Ttn  of  an  inch)  and 
even  narrower,  while  others  are  as  much  as  .05  millimetre 
(s^jjth  of  an  inch)  wide.  There  is  no  doubt  that  some 
of  these  are  formed  in  the  straight  or  collecting  tubes  near 


URINARY   DEPOSITS.  145 

their  openings  on  the  papilla.     To  these  a  limited  number 
of  epithelial  cells  is  sometimes  attached. 


Oil-casts  and  fatty  epithelium. 

In  addition  to  the  epithelial  casts  above  described,  there 
are  found  in  urine  under  the  same  circumstances  moulds  of 
the  uriniferous  tubules  made  up  of  simple  aggregations  of 
the  epithelial  cells  themselves — simple  exfoliations  of  the  cel- 
lular contents  of  the  tubule,  which  having  increased  by  pro- 
liferation form  a  compact  cellular  mass.  In  addition  to 
these  also  are  sometimes  found  epithelial  casts  in  which 
the  cells  are  seated  on  the  outside  or  around  the  fibrinous 
mould. 

Mucus-casts Casts  are  occasionally  found,  which  are 

apparently  pure  mucus-moulds  of  the  uriniferous  tubules. 
Unless  covered  by  accidental  elements,  as  granular  unites 
.or  phosphate  of  lime,  they  are  smooth,  hyaline  or  gently 
fibrillated  moulds,  especially  characterized  by  their  great 
13 


146      PKACTICAL   EXAMINATION   OF   THE   URINE. 

length,  which  is  often  enormous,  in  the  course  of  which  they 
divide  and  subdivide,  diminishing  in  diameter  as  the  division 
proceeds,  showing  positively  that  they  come  from  the  kidney. 
Yet  there  is  no  albumen  or  merely  as  much  as  could  be  ac- 
counted for  by  the  presence  of  pus  which  sometimes  attends 
them.  For  they  are  particularly  apt  to  occur  where  there  is 
irritation  of  the  bladder,  which  is  apparently  extended 
through  the  ureters  to  the  kidney.  Under  these  circum- 
stances, I  have  met  them  on  two  or  three  occasions.  Dr. 
Beale  says  (Kidney  Diseases,  etc.,  p.  342),  they  are  not  un- 
frequently  passed  in  cases  where  the  urine  has  a  very  high 
specific  gravity,  1030  or  higher,  containing  an  excess  of  urea 
and  urates. 

These  casts  are  not  identical  with  the  bands  of  mucin 
already  alluded  to  (p.  131),  which  are  found  in  the  urine  of 
highly  acid  reaction,  perhaps  precipitated  by  the  acids, 
which  are  often  beset  with  granular  urates,  and  might  be 
mistaken  for  casts. 

Casts  of  the  seminal  tubules  are  sometimes  found  in  the 
urine,  but  their  origin  may  be  inferred  from  the  presence  of 
spermatozoids  in  them. 

lo  Prepare  Urine  for  Examination  for  Casts The 

greatest  caution  should  be  exercised  in  examining  urine  for 
casts.  They  are  often  so  sparsely  present  as  to  furnish  no 
deposit  appreciable  to  the  naked  eye,  and  yet  may  be  found 
by  careful  microscopical  examination.  While  it  is  not  im- 
possible for  non-albuminous  urine  to  contain  casts,  yet  I 
have  never  met  them,  except  in  two  or  three  instances, 
where,  albumen  and  casts  having  been  present,  in  their  gradual 
disappearance  the  signs  of  the  presence  of  albumen  disap- 
peared before  the  last  casts  had  been  washed  out.  On  the 
other  hand  the  presence  of  albumen  means  casts  in  the  vast 


URINARY   DEPOSITS.  147 

majority  of  instances,  and  many  times  I  am  certain  they  are 
declared  absent,  simply  because  they  are  not  carefully  sought. 
At  present  I  have  a  case  under  my  observation  in  which  the 
urine  contains  £th  its  bulk  of  albumen,  and  yet  by  the  most 
searching  examination  I  fail  to  find  casts.  Not  a  single  slide, 
however,  should  satisfy  the  examiner,  but  two  or  three  should 
be  carefully  studied  throughout  their  entire  field.  Nor  is  a 
plain  slide  sufficient.  Urine  should  be  examined  in  shallow 
cells,  and  as  those  of  thin  glass  are  generally  too  deep,  the 
best  are  made  with  gum-dammar  or  Bell's  cement,  by  means 
of  a  turntable  and  brush,  since  in  this  way  they  may  be  ob- 
tained sufficiently  shallow  to  allow  them  to  be  penetrated  by 
an  ordinary  one-fifth  or  one-fourth  objective.  After  being 
made  they  should  be  put  away  for  a  month  or  more  to 
thoroughly  dry  and  harden,  else  they  are  washed  off  with 
the  first  cleaning  of  the  slide. 

Most  casts  from  their  lightness  subside  slowly,  and  the 
more  so  because  the  urine  is  albuminous.  As  soon  as  re- 
ceived, therefore,  the  bottle  of  urine  should  be  shaken  up, 
poured  into  a  conical  glass,  and  carefully  covered.  Although 
casts  generally  fall  to  the  bottom  in  a  shorter  time,  I  have 
known  twelve  hours  to  elapse  before  one  could  be  discovered, 
and  therefore  whenever  it  is  possible,  urine  should  be  al- 
lowed to  stand  for  this  time  in  a  conical  glass,  and  then 
examined.  If  the  urine  has  already  been  standing  some 
time,  the  supernatant  fluid  may  be  removed,  and  only  the 
lower  strata  containing  the  sediment  turned  into  the  conical 
glass,  and  allowed  further  to  subside.  A  pipette,  consisting 
of  a  plain  glass-tube  drawn  nearly  to  a  point,  should  then 
be  carried  to  the  bottom  of  the  glass  with  the  index  finger 
firmly  pressed  upon  the  distal  end.  When  it  has  reached 
the  bottom,  the  finger  should  be  raised,  and  immediately 


148      PRACTICAL   EXAMINATION    OF   THE    URINE. 

returned.  In  this  manner  only  the  lowest  drops  are  ob- 
tained, which  are  most  likely  to  contain  the  casts.  A 
drop  of  this  fluid  is  allowed  to  fall  into  one  of  the  shallow 
cells,  covered  with  a  thin  glass  cover,  and  carefully  exam- 
ined with  a  one-fourth  or  one-fifth  object-glass  and  the  No.  1 
eye-piece.  If  these  precautions  are  taken,  and  two  or  three 
slides  examined,  casts  will  either  be  found,  or  they  are  ab- 
sent. Only  the  beginner  need  be  cautioned  against  linen 
and  cotton  fibre,  hair,  or  portions  of  deal-wood.  More  likely 
are  the  mucin  flakes  and  cast-like  granular  aggregations  of 
inorganic  and  organic  matter  to  mislead. 

V.  SPERMATOZOIDS  frequently  occur  in  the  sediment  of 
urine  of  healthy  individuals.  When  abundant,  they  form  a 
slight  flocculent  cloud  in  the  urine,  but  there  is  generally 
nothing  in  the  appearance  of  urine  whence  their  presence 
may  be  suspected.  They  require  a  power  of  400  diameters 
(one-fifth  with  the  No.  2  eye-piece)  to  show  them  well,  when 
they  may  be  recognized  by  the  oval  head  or  body  and  the 
delicate  tail-like  prolongation  emanating  from  it.  They  no 
longer  exhibit  their  vibratile  movement  after  entering  the 
urine.  Their  recognition  is  most  interesting  in  connection 
with  medico-legal  cases — cases  of  suspected  rape.  Their 
presence  in  vaginal  mucus  soon  after  coition,  and  in  stains 
upon  linen,  is  easy  of  demonstration.  In  the  former  case  a 
drop  of  mucus  from  within  the  vagina  is  placed  upon  a  slide, 
a  drop  of  water  added  if  necessary,  covered  with  a  thin 
cover,  and  examined  with  the  microscope.  In  the  latter  a 
simple  piece  of  the  stained  linen  may  be  soaked  in  water  or 
artificial  serum  in  a  watch-glass  for  half  an  hour  or  an  hour, 
and  the  sediment  examined.  Beale  figures  (Fig.  74)  some 
filaments  of  a  vegetable  nature  resembling  spermatozoids. 
VI.  FUNGI Most  of  the  living  organisms  found  in  de- 


URINARY   DEPOSITS. 


149 


composing  urine,  formerly  looked  upon  as  of  animal  origin, 
are  now  acknowledged  to  be  vegetable  in  their  nature,  and 
are  generally  fungi. 

The  most  frequent  among  these  are  bacteria,  penicilium 
glaucum,  and  the  yeast  fungus.  Sarcinee  are  occasionally 
met  with. 


Human  spermatozoids.    1.  Magnified  350  diameters.    2.  800  diameters. 
a,  viewed  from  the  side.    &,  from  the  front. 

1.  Bacteria — In  the  refined  study  which  has  of  late  years 
been  given  to  the  subject  of  fungi,  a  classification  has  been 
made  of  the  minute  objects  which  were  formerly  called  bac- 
teria or  vibriones.  I  take  from  Hoffmann  and  Ultzmann 
the  classification  of  A.  Vogel,  who  makes  of  them,  a,  the 
monad  form,  consisting  of  little  trembling  points  distin- 
guished in  their  molecular  movement  from  that  of  inorganic 
particles,  by  a  progressive  motion ;  b,  the  staff-shaped  bac- 
teria, which  appear  as  minute  lines  equalling  in  length  with 
moderate  powers  the  diameter  of  a  red  blood-disk,  but  mere 
13* 


150      PEACTICAL  EXAMINATION   OF   THE   URINE. 

lines  in  breadth,  sometimes  at  rest,  and  sometimes  vibrating 
across  the  field ;  c,  the  vibrio  form,  consisting  of  two  or 
more  of  the  staff-shaped  bacteria,  adherent  end  to  end,  and 
moving  often  with  great  rapidity,  sometimes  by  a  spiral 
movement,  and  sometimes  by  vibrating  one  extremity,  as  a 
fish  propels  itself ;  e?,  the  leptothrix  form  or  chain  fungus, 
often  extending  entirely  across  the  field  of  view,  differing 
from  the  vibrio  forms  only  by  their  length,  moving  seldom, 
and  if  at  all  very  slowly  ;  e,  the  zooglea  form,  consisting  of 
heaps  of  bacteria,  mostly  punctiform,  apparently  held  to- 
gether by  a  gelatinous  substance. 

2.  The  yeast  or  sugar  fungus,  identical  with  the  ordinary 
yeast  fungus,  consists  in  the  sporule-stage  of  transparent  oval 
cells,  in  their  longer  diameter  about  the  size  of  a  blood-disk, 
and  of  larger  spherical  cells,  granular  and  nucleated,  found 
in  saccharine  urine.  (Fig.  31.)  According  to  Hassall,  this 


is  a  fungus  peculiar  to  saccharine  urine,  but  the  small  oval 
cells  of  the  sporule-stage  at  least  cannot  be  distinguished 
from  the  similar  stage  of 

3.  Penicilium  glaucum,  which  occurs  in  acid  urine  with 
or  without  albumen  or  sugar.  The  sporule-stage  furnishes 
cells  very  similar  to  those  of  the  yeast  fungus,  but,  later 


URINARY    DEPOSITS.  151 

penicilium,  by  the  union  of  its  cells,  forms  thalli  or  branches 
which  are  characteristic.  So,  too,  in  the  stage  of  aerial 
fructification,  the  penicilium  multiplies  by  simple  linear  di- 
vision of  cells,  while  the  spores  of  the  sugar  fungus  fall  from 
a  spherical  mass  not  unlike  that  on  the  stem  of  an  onion 
"going  to  seed." 

4.  The  sarcina  is  a  fungus  rarely  met  with  in  urine. 
Composed  of  cubes,  it  is  capable  of  further  separation  into 
smaller  cubes.  It  is  similar  to,  but  smaller  than,  the 
sarcina  ventriculi  of  Goodsir. 

The  germs  of  these  fungi  doubtless  enter  the  urine  after 
it  has  passed  from  the  bladder,  in  the  vast  majority  of  in- 
stances, one  or  the  other  form  being  developed  according  as 
its  germs  preponderate,  or  according  to  the  properties  the 
urine  may  possess.  Decomposition  seems  essential  to  the 
presence  of  the  bacteria,  but  not  to  the  other  forms. 

VII.  THE   ELEMENTS    OF  MORBID    GROWTHS — These 
are  seldom  met  in  the  urine.     Possibly  cells  may  be  found, 
and  perhaps  fragments  of  the  growth  may  be  broken  off'  and 
passed  with  the  urine.     The  former  may  be  suspected  to  be 
of  morbid  origin  by  their  large  size,  their  multinuclear  cha- 
racter, the  large  size  of  the  nuclei,  and  diversity  of  the  cell- 
forms.     Spindle-cells,  it  must  be  remembered,  may  he  de- 
rived from  the  ureter,  urethra,  and  even  the  bladder,  and 
must  not,  therefore,  be  considered  abnormal. 

Fragments  of  cancerous  growths  which  get  into  the  urine 
are  generally  from  the  villous  kind,  and  may  show  the  capil- 
lary vessels  which  make  up  the  villus,  with  or  without  the 
epithelial  covering.  Fragments,  suitable. for  examination, 
are  sometimes  withdrawn  with  the  catheter. 

VIII.  ENTOZOA — Entozoa  are  seldom  found  in  the  urine 
in  this  climate.     Echinococcus  cysts,  as  well  as  their  hook- 


152      PRACTICAL   EXAMINATION   OF   THE   URINE. 

lets,  have  been  passed  in  two  or  three  instances  recorded. 
The  eggs  and  ciliated  embryos  of  Bilharzia  kcematobia  have 
been  found  by  Dr.  John  Harley  in  three  patients  with  the 
endemic  haematuria  of  the  Cape  of  Good  Hope,  and  I  had 
the  privilege,  through  the  kindness  of  my  friend,  Dr.  S.  W. 
Gross,  of  examining  one  of  the  slides  containing  ova.  sent  to 
this  country.  The  parasite  itself  is  found  in  the  vesical, 
mesenteric,  and  portal  veins,  causing  hemorrhages  into  the 
intestines,  bladder,  ureters,  and  pelves  of  the  kidney.  The 
ova  and  parasite  are  figured  by  Beale,  op.,  p.  402. 

Distoma  heematobium  has  been   found  in    the   bladder, 
ureters,  and  pelves  of  the  kidney,  especially  in  Egypt. 


DIAGNOSIS    OF    RENAL    DISEASES.  153 


DIFFERENTIAL  DIAGNOSIS  OF  RENAL  DISEASES. 

WHILE  it  is  quite  impossible  to  determine  with  absolute 
certainty  all  of  the  different  affections  to  which  the  kidneys 
are  liable  by  a  mere  examination  of  the  urine,  there  is 
nevertheless  an  association  more  or  less  close  of  signs  with 
well-determined  conditions.  With  such  association  it  is 
important  that  we  should  be  familiar,  while  we  should  as 
well  recognize  the  fact  that  they  are  subject  to  variations 
and  exceptions.  If  these  truths  are  properly  remembered, 
it  is  not  likely  that  any  one  can  be  led  far  astray  by  observ- 
ing the  following : — 

I.  Acute  Nephritis  (Scarlatinal  Nephritis) — The  urine 
is  scanty,  dark,  "  smoke-hued,"  so  long  as  it  remains  acid, 
but  becomes  red  if  alkalized.  It  is  highly  albuminous.  Its 
specific  gravity  is  not  constant,  but  apt  to  be  high — 1025  or 
above — not  from  an  increase  in  urea,  but  from  the  presence 
of  blood.  It  contains  a  variable,  but  generally  large  amount 
of  reddish-brown,  pulverulent  sediment,  which,  on  micro- 
scopic examination,  is  found  made  up  of  large  epithelial  casts, 
blood-casts,  hyaline  casts  of  large  diameter,  dark -red  granular 
casts,  numerous  red  blood-disks,  and  free  cells,  more  or  less 
round  and  nucleated,  twice  as  wide  as  the  blood-disks, 
cloudy,  and  more  granular  than  in  health,  the  granules  often 
obscuring  the  nucleus.  Crystals  of  uric  acid  are  often  pre- 
sent. The  chlorides  are  at  first  diminished,  also  the  earthy 
phosphates.  Hscmatin,  indican,  and  uric  acid  are  increased. 

The  patient  is  dropsical,  much  swollen  about  the  face, 


154      PRACTICAL   EXAMINATION   OF   THE   URINE. 

and,  if  a  child,  has  had  scarlet  fever,  or,  jf  an  adult,  has 
been  exposed  to  wet  while  perspiring. 

The  disease  is  acute  nephritis,  scarlatinal  nephritis,  or 
acute  Bright's  disease,  and  the  chances  for  recovery  are 
many. 

II.  Chronic     Tubal    Nephritis    ( Parenchymatous    Ne- 
phritis;    Large   White  Kidney) The  urine  is  pale,  and 

of  low.  specific  gravity — 1005—1015;    its  quantity,  though 
variable,  generally  diminished.     Albumen  is  diminished  as 
compared   with    (I.),    but   is    still    abundant — one-quarter 
to   one-half  the   bulk.     It   deposits   an   appreciable   white 
sediment,    which,    by    microscopic    examination,    is    found 
made  up  of  black,  highly  granular  casts,  hyaline  casts,  and 
casts   containing  fragments   of  epithelium ;  also   compound 
granule-cells  (Fig.  25).     Probably  also  there  are  casts  con- 
taining a  moderate  quantity  of  oil,  and  perhaps  also  partially 
fatty  cells.     Waxy  casts  are  also  sometimes  found  in  this 
form  of  disease.     The  urea  is  diminished,  the  chlorides  nor- 
mal, pigment  diminished.     There  is  also  oedema,  more  or 
less  general,  which  may,  however,  subside,  but  the  patient 
has  a  pale,  almost  characteristic  waxy  look.     The  symptoms 
have  existed  more  than  six  weeks. 

The  disease  is  probably  the  large  white  kidney,  a  chronic 
continuation  of  (I.),  known  also  as  chronic  tubal  nephritis, 
and  recovery,  though  possible,  is  not  likely  to  occur. 

III.  Yellow  Fatty  Kidney — The  urine  presents  the  same 
general  characters  as  in  the  last  case,  contains  rather  more 
albumen,  and  a  more  abundant  sediment,  which  is  found 
made  up  of  numerous  oil-casts  filled  with  free  oil,  and  oil 
contained  in  epithelial  cells.     There  are  myperous  free  fatty 
cells  and  free  oil-globules.     The  urea  is  diminished. 

It  is  the  true  yellow  fatty  kidney,  which,  sometimes  at 


DIAGNOSIS   OF   RENAL   DISEASES.  155 

least,  originates  independently  of  any  acute  inflammation  of 
the  organ  in  drunkards.  Dropsy  is  persistent.  The  disease 
is  pre-eminently  fatal.  The  patient  exhibiting  the  peculiar 
cachexia  mentioned  under  (II.)  will  generally  perish  within 
the  year. 

IV.  Secondary  Contraction  of  the  Kidney  after  Chronic 
Nephritis — The  disease  has  existed  for  more  than  a  year, 
the  urine  is  small  in  amount,  though  pale  in  color,  but  is 
perhaps  not  so  mucli  diminished,  and  the  specific  gravity  is 
somewhat  higher  than  in  (II.).     The  albumen  is  diminished 
but  is  still  considerable.     The  urine  deposits  a  more  scanty 
sediment,  made  up  of  broad  casts,  some  dark  granules,  and 
others  contain  fragments  of  waxy,  together  with  a  few  nar- 
row pale  casts.     Compound  granule-cells  occur,  but  are  less 
numerous,  and  there  may  be  some  fatty  epithelial  cells,  but 
the  amount  of  oil,  though  distinctive,  is  not  very  large.    The 
urea  is  much  diminished.     There  is  generally  some  dropsy, 
less  than  in  (I.),  (II.),  and  (III.),  but  more  than  in  (V.). 

Here  the  large  white  kidney  has  probably  commenced  to 
contract,  but  one  must  be  cautious  about  drawing  too  sharp 
a  line  between  these  two  affections.  The  prognosis  is  un- 
favorable, but  the  disease  may  last  some  time — even  years. 

V.  Interstitial  Nephritis  (chronically  contracted  Kidney). 
— The  urine  is  increased  in  amount,  correspondingly  pale, 
but,  while  micturition  may  be  a  little  more  frequent,  it  may 
not  attract  attention.     The  patient  may  have  to  rise  once  in 
the  night.    The  specific  gravity  is  little,  if  at  all,  diminished, 
(1018-20) — while  the  quantity  of  albumen  is  trifling,  never 
exceeds  one-quarter,  and  often  is  shown  by  a  mere  line  of 
opacity  in  Heller's  test.     It  deposits  often  no  visible  sedi- 
ment, and  at  all  times  a  trifling  one.    In  this  are  found  deli- 
cate hyaline  and  finely  granular  casts,  often  of  small  diameter. 


156      PRACTICAL   EXAMINATION   OF   THE   URINE. 

Some  of  these  contain  one  or  two  glistening  oil-drops,  but 
very  minute.  Here  are  found  the  casts  which  are  at  times 
almost  invisible.  The  urea  is  generally  slightly  diminished. 

There  is  no  dropsy.  There  are  often  no  symptoms  what- 
ever connected  with  the  disease.  If  any,  the  patient  may 
complain  of  a  weak,  tired  feeling,  and  this  symptom  should 
suggest  an  examination  of  the  urine  always.  The  disease 
may  exist  for  years  without  the  knowledge  of  the  patient, 
who  may  or  may  not  be  subject  to  gout.  (The  urine  of 
gouty  patients  should  be  frequently  examined.) 

The  disease  is  the  chronically  contracted  kidney,  the  in- 
terstitial nephritis  of  the  German  pathologists.  If  exposure 
to  cold  and  fatigue  be  avoided,  the  patient's  life  may  be 
scarcely  shortened,  and  yet  he  is  constantly  liable  to  attacks 
of  ursemia,  which  may  suddenly  terminate  his  life. 

VI.  Albuminoid  or  Amyloid  Degeneration  of  the  Kidney. 
— The  urine  is  increased  in  quantity,  clear,  of  corresponding 
specific  gravity  (1007-1015),  of  a  pale,  golden  color,  the 
color  of  a  dilute  urine  only,  contains  considerable  albumen, 
about  one-fourth  to  one-half;  urea  is  diminished.  There  is 
very  little  or  no  sediment  visible.  Casts  are  often  wanting, 
and  when  present  include  the  broad  dark  granular  as  well  as 
the  hyaline  and  waxy,  though  the  latter  by  no  means  always  ; 
occasionally  fatty  casts  are  found  ;  the  waxy  are  solid  look- 
ing, and  sometimes  giving  the  characteristic  red  reaction  of 
the  albuminoid  substance  when  treated  with  a  watery  solu- 
tion of  iodine  and  iodide  of  potassium.  Here  hyaline  and 
waxy  casts  of  large  diameter  are  found,  and  sometimes 
within  these  smaller  casts. 

While  the  highly  refracting  waxy  casts  are  not  confined 
to  albuminoid  kidney,  they  always  indicate  chronic  and  deep- 
seated  processes. 


DIAGNOSIS   OF   RENAL   DISEASES.  157 

There  is  apt  to  be  dropsy,  sometimes  persistent,  but  gene- 
rally, except  towards  the  termination  of  the  case,  amenable 
to  treatment  by  rest  and  diuretics.  The  patient  has  an 
enlarged  liver  or  spleen,  sometimes  persistent  diarrhoea ;  he 
has  had  syphilis,  or  extensive  disease  of  the  bones,  or  has 
phthisis. 

The  disease  is  albuminoid  degeneration  of  the  kidney,  and 
is  incurable,  though  the  patient  may  live  many  years. 

VII.  Parencliymatous  Degeneration  of  the  Kidney. — 
Most  frequently  the  sole  symptom  is  albuminuria,  the  most 
careful  examination  failing  to  discover  casts.  There  is,  as  a 
rule,  no  dropsy.  The  quantity  of  albumen  (T^  to  £  bulk)  is 
generally  less  than  in  tubal  or  parenchymatous  inflammation, 
or  albuminoid  degeneration.  Such  is  sometimes  the  albumi- 
nuria of  pregnancy  or  such  grave  diseases  as  diphtheria  and 
acute  febrile  disorders. 

After  death,  the  renal  epithelia  are  often  more  or  less 
enlarged  by  albuminous  exudation,  their  contents  cloudy. 
This  condition  differs  from  parenchymatous  nephritis  in  the 
smaller  extent  and  diminished  intensity  of  the  morbid  pro- 
cess. It  is  probably  due  to  the  pernicious  influence  of  some 
poison  on  the  minute  structure  of  the  tissue  of  the  kidney, 
which  may  extend  to  all  the  tissues.  Recovery  is  frequent. 

The  disease  is  called  by  Niemeyer  parenchymatous  dege- 
neration. 

The  above  is  given  as  a  general  guide,  and  I  would  again 
refer  to  the  fact  that  there  are  deviations  from  the  conditions 
laid  down.  There  are  still  many  points  quite  disputed  in 
the  pathology  of  the  kidney.  Thus,  the  German  patholo- 
gists  contend  that  there  is  a  constant  relation  of  succession 
between  the  acute  parenchymatous  nephritis,  the  chronic 


158      PRACTICAL   EXAMINATION   OF   THE   URINE. 

parenchymatous  nephritis  (large  white  kidney),  and  the  con- 
tracting stage  of  the  latter,  making  no  distinction  between 
the  large  white  kidney  and  the  fatty  kidney.  Both,  it  is 
true,  are  fatty  kidneys,  but  while  the  fat  in  the  former  is 
molecular  or  granular  fat,  in  the  latter  it  is  globular.  Al- 
though these  two  may  also,  at  times,  be  different  stages,  the 
latter  being  the  more  advanced,  no  fact  is  better  determined 
than  that  the  true  fatty  kidney  may  originate  insidiously 
without  any  acute  attack. 

One  more  fact  must  be  mentioned  in  this  connection,  and 
this  is,  that  although  the  presence  of  fatty  casts  and  fatty 
epithelium  are  unfavorable  symptoms,  yet  it  does  not  follow 
that  such  cases  are  necessarily  fatal.  I  have,  on  more  than 
one  occasion,  found  oil-casts  in  the  urine  of  patients,  and 
yet  have  also  found  them  to  disappear  altogether.  The  cir- 
cumstances under  which  this  has  occurred  have  been,  1st, 
where  there  have  been  heart-disease  and  kidney-disease  com- 
bined, and  there  has  been  some  exacerbation  of  one  or  both, 
when  the  albumen  has  increased,  and  oil-casts  have  made 
their  appearance,  which  later  totally  disappeared  ;  2d,  where 
pregnancy  has  supervened  on  existing  Bright's  disease,  and 
oil-casts  have  been  present,  which  again  disappeared  after  a 
successful  labor. 


URINARY   CALCULI.  159 


URINARY  CALCULI. 

THE  qualitative  analysis  of  gravel  or  calculi  is  much  sim- 
pler than  is  generally  supposed.  There  are  but  three  forms 
of  calculi  which  are  of  at  all  common  occurrence,  and  which 
are,  therefore,  likely  to  demand  analysis.  These  are  uric 
acid  and  compounds,  oxalate  of  lime,  and  the  mixed  phos- 
phates. Calculi  of  xanthine  and  cystine  are  found,  though 
very  rarely. 

1.  Uric  acid  calculi  are  the  most  common.     They  are 
either  red  or  some  shade  of  red,  and  usually  smooth,  but 
may  be  tuberculated.     They  leave  a  mere  trace  of  residue 
after  ignition. 

2.  Oxalate  of  lime  calculi  are  frequently  met  with.    They 
are  generally  of  a  dark-brown  or  dark-gray  color,  and  from 
their  frequently  tuberculated  surface  have  been  called  mul- 
berry calculi.     They  may,  however,  also  be  smooth.     Con- 
siderable residue  remains  after  ignition.       The  calculus  is 
soluble  in  mineral  acids  without  effervescence. 

3.  Calculi  of  the  mixed  phosphates  or  fusible  calculi  are 
composed  of  the  phosphate  of  lime  and  of  the  triple  phosphate 
of  ammonia  and  magnesia.    They  form  the  external  layer  of 
many  calculi  of  different  composition,  and  may  form  entire 
calculi,  but  very  seldom  form  the  nuclei  of  other  calculi. 
They  are  white,  exceedingly  brittle,  fuse  in   the  blowpipe 
flame,  and  are  soluble  in  acids,  but  insoluble  in  alkalies. 

Few  calculi  of  large  'size  are  of  the  same  composition 
throughout.  Oxalate  of  lime  is  the  most  frequent  nucleus  ; 
uric  acid  may  also  serve  as  a  nucleus,  but  phosphates,  as 
stated,  almost  never.  Small  collections  of  organic  matter, 
as  blood-clots,  frequently  form  nuclei,  and  may  often  be 


160      PRACTICAL   EXAMINATION   OF   THE   URINE. 

recognized  by  the  odor  of  ammonia  on  ignition.  It  is  not 
uncommon  to  find  calculi  made  up  of  concentric  layers  of 
different  composition. 

To  Determine  the  Composition  of  Calculi.* 

Heat  a  portion  of  the  powdered  calculus  to  redness  upon 
platinum  foil.  Note  whether  there  is  a  residue. 

A.   There  is  a  fixed  residue.     To  a  portion  of  the  original 
powder  apply  the  murexid  test  (p.  91). 

I.  A  purple  color  results ;  uric  acid  is  present.     Ob- 
serve whether  a  portion  of  the  calculus  melts  on  being 
heated. 

a.  It  melts,  and  communicates — 

1.  A  strong  yellow  color  to  the  flame  of  a 
spirit  lamp  ;  soditim  urate. 

2.  A  violet  color  to  the   flame ;  potassium 
urate. 

b.  It  does  not  melt.     Dissolve  the  residue  after 
ignition  in  a  little  dilute  HC1,  add  ammonia 
until  alkaline,  and  then  ammonium  carbonate 
solution. 

1.  A  white  precipitate  falls;  calcium  urate. 

2.  No  precipitate.     Add  some   hydric  sodic 
phosphate    solution ;    a    white    crystalline 
precipitate  falls  ;  magnesium  urate. 

II.  No  purple  color  results.     Observe  whether  a  por- 
tion of  the  calculus  melts  on  being  heated  strongly. 

a.  It  melts  (fusible  calculus).     Treat  the  residue 

*  The  processes  here  given  are  taken,  with  slight  verbal  altera- 
tions, from  the  last  edition  of  Thudicum's  work  on  the  Pathology 
of  the  Urine. 


URINARY   CALCULI.  161 

with  acetic  acid  ;  it  dissolves.  Add  (o  the  solu- 
tion ammonia  in  excess ;  a  white  crystalline 
precipitate  falls ;  ammonio-magnesium  phos- 
phate. In  case  the  melted  residue  is  insoluble 
in  acetic  acid,  treat  with  HC1 ;  it  dissolves. 
Add  to  the  solution  ammonia  ;  a  white  precipi- 
tate indicates  calcium  phosphate, 
b.  It  does  not  melt.  Moisten  the  residue  with 
water,  and  test  its  reaction  with  litmus  paper; 
it  is  not  alkaline.  Treat  with  HC1 ;  it  dissolves 
without  effervescence.  Add  to  the  solution  am- 
monia in  excess;  white  precipitate;  calcium 
phosphate.  Treat  the  calculus  with  acetic  acid; 
it  does  not  dissolve.  Treat  the  residue  after 
heating  with  acetic  acid ;  it  dissolves  with  effer- 
vescence ;  calcium  oxalate.  Treat  the  original 
calculus  with  acetic  acid  ;  it  dissolves  with  effer- 
vescence ;  calcium  carbonate. 

B.  Tliere  is  no  fixed  residue.     Apply  the  murexid  test  (p.  9 1 ) . 

I.  A  purple  color  is  developed. 

a.  Mix  a  portion  of  the  powdered  calculus  with  a 
little  lime,  and  moisten  with  a  little  water ;  am- 
monia is.  evolved,  and  a  red  litmus  paper  sus- 
pended over  the  mass  is  turned  blue ;  ammonium 
urate. 

b.  No  ammonia  ;  uric  acid. 

II.  No  purple  color. 

a.  But  the  nitric  acid  solution  turns  yellow  as  it  is 
evaporated,  and  leaves   a  residue  insoluble  in 
potassium  carbonate ;  xanthine. 

b.  The  nitric  acid  solution  turns  dark  brown,  and 
leaves  a  residue  soluble  in  ammonia;  cystine. 

14* 


162      PRACTICAL   EXAMINATION   OF   THE   URINE. 
MODE  OF  RECORDING  AN  EXAMINATION. 

To  systematize  and  facilitate  the  work  of  urine  examina- 
tions, forms  of  record  have  been  devised  by  those  working 
in  the  subject.  I  formerly  used,  with  great  convenience, 
that  suggested  by  Prof.  Austin  Flint,  Jr.,  in  his  manual  on 
the  Chemical  Examination  of  Urine,  but  for  ordinary  use  in 
hospital  and  private  practice  that  of  Heller  recommends 
itself  for  its  economy  and  readiness. 

Heller  recommends  that  an  ordinary  half-sheet  of  letter 
paper  be  folded  in  four,  and  marked  as  indicated  below  : — 


PHYSICAL  PROPERTIES. 

Quantity  in  twenty-four  hours, 

Color  and  reaction, 

Sp.  gr.,     Quantity  and  character  of  sediment. 


NORMAL  CONSTITUENTS. 


Uph.  (Urophain.)  Cl.  (Chlorides.) 

Ux.  (Uroxanthin.)  Epli.  (Earthy  phosphates.) 

U.  (Urea.)  Alkaline  phosphates. 

U.  (Uric  acid.)  Sulphates.     . 


ABNORMAL  CONSTITUENTS  IN  SOLUTION. 


SEDIMENT. 


KECORDING   AN   EXAMINATION.  163 

Abbreviations  for  the  important  constituents  are  used  as 
shown,  and  the  sign  "  -}-"  for  increased,  the  sign  "  —  "  for 
diminished,  and  the  letter  "  n "  for  normal.  For  great 

increase  or  great  diminution,  "gr.  -|-"  and  "  gr "  may  be 

used,  and  for  slight  increase  or  slight  diminution,  "  si.  ~\- " 
or  "  si " 

Let  us  suppose  an  examination  to  have  been  made,  with 
the  following  results.  The  word  "  indican,"  "  ind."  is  pre- 
ferred for  "  uroxanthin,"  and  substituted. 


PHYSICAL  PROPERTIES. 

Quantity  in  twenty-four  hours,          500  c.  c. 
Color,  very  pale-yellow.  Reaction,  acid. 

Sp.  gr.  1005.    Sediment,  moderate,  flocculent. 


NORMAL  CONSTITUENTS. 

Uph.  gr.  —  Cl. 

Ind.    si.  +  Eph. 


Aph.      (.     - 
Sph. 


ABNORMAL  CONSTITUENTS  IN  SOLUTION. 
Albumen,  50  per  cent. 


SEDIMENT. 

Numerous  oil-casts,  free  fatty  cells,  and  free 
oil-globules. 

Diagnosis — Fatty  kidney. 


164      PRACTICAL   EXAMINATION   OF   THE   URINE.- 


TABLES 

For  Reducing  the  Metric  or  French  System  into  the  English, 
a,  as  far  as  required  in  Urinary  Analysis. 


and 


vice  versa 


Grammes  to  Grains. 


Grains  to  Milligrammes. 


1     =     15.43  (+  .0022) 

1 

=       64.8  (—.000425) 

2    =     30.86 

2 

=     120-6 

3    =    46.29 

3 

=    194.4 

4     =     61.72 

4 

=     259.2 

5    =     77.15 

5 

=     324.0 

6     =     92.58 

6 

=     388.8 

7     =  108.01 

7 

=    453.6     . 

8     =  123.44 

8 

=     518.4 

9     =  138.87 

9 

=     583.2 

Cubic  Centimetres  to  Minims. 

Minims  to  Cubic  Centimetres. 

1     =     16.2  (+  .0293) 

1 

=     .0616 

2     =       32.4 

2 

=     .1232 

3     =       48.6 

3 

=     .1848 

4    =      64.8 

4 

=    .2464 

5     =       81.0 

5 

=     .3080 

6     =       97.2 

6 

=     .3696 

7    =    113.4 

7 

=     .4312 

8     =     129.6 

8 

=     .4928 

9     =     145.8 

9 

=     .5544 

Cubic  Centimetres  to 

Fluidrachms  to  Cubic 

Fluidrachms. 

Centimetres. 

1      =        .27  (+  .0005) 

1 

=        3.7 

2    =       .54 

2 

=      7.4 

3    =      .81 

3 

=   11.1 

4    =    1.08 

4 

=     14.8 

5     =     1.35 

5 

=    18.5 

6     =     1.62 

6 

=    22.2 

7    —    1.89 

7 

=     25.9 

8    =    2.16 

8 

=     29.6 

9    =    2.43 

9 

=     33.3 

TABLES. 


165 


Litres  to  Fluidounces. 


Fluidounces  to  Cubic  Centimetres. 


1 

= 

33.8  (4-  .011) 

1 

= 

30  (_  .4238) 

2 

5=5 

67.6 

2 

55= 

60 

3 

55= 

101.4 

3 

— 

90 

4 

5= 

135.2 

4 

= 

120 

5 

= 

169.0 

5 

» 

150 

6 

= 

202.8 

6 

= 

180 

7 

= 

236.6 

7 

5= 

210 

8 

= 

270.4 

8 

— 

240 

9 

= 

304.2 

9 

= 

270 

Litres  to  Pints. 

Pints  to 

Litres. 

1 

= 

2.1  (4-  .013188) 

1 

= 

.473  (4-.  00022) 

2 

=5 

4.2 

2 

= 

.946 

3 

— 

6.3 

3 

= 

1.419 

4 



8.4 

4 

= 

1.892 

5 

5= 

10.5 

5 

= 

2.365 

6 

= 

12.6 

6 

— 

2.838 

7 

= 

14.7 

7 

— 

3.311 

8 

=5= 

16.8 

8 

= 

3.784 

9 

= 

18.9 

9 

= 

4.257 

Inches  to  Millimetres. 

Millimetres  to  Inches. 

1 

= 

25.4  (4-  .00005) 

1 

= 

.03937 

2 

= 

50.8 

2 

= 

.07874 

3 

— 

76.2 

3 

= 

.11811 

4 

5= 

101.6 

4 

=C 

.15748 

5 

=5 

127.0 

5 

= 

.19685 

6 

= 

152.4 

6 

=55 

.23622 

7 

— 

177.8 

7 

= 

.27559 

8 

5= 

193.2 

8 

5= 

.31496 

9 

55= 

228.6 

9 

= 

.35432 

166      PRACTICAL   EXAMINATION    OF   THE   URINE. 


Metres  to  Feet. 


3.28 

6.56 

9.84 

13.12 

16.40 

19.68 

22.96 

26.24 

29.52 


Feet  to  Metres. 

1  =  .3048  (4-  .0000005) 

2  =  .6096 

3  =  .9144 

4  =  1.2192 

5  =  1.5240 

6  =  1.8288 

7  =  2.1336 

8  =  2.4384 

9  =  2.7432 


To  Convert  Degrees  of  Fahrenheit's  Thermometer  to 
Centigrade,  and  vice  versa. 


Centigrade  to  Fahrenheit. 


1  = 

2  = 

3  = 

4  = 

5  = 

6  = 

7  = 

8  = 

Q  _. 


1.8 

3.6 

5.4 

7.2 

9.0 

10.8 

12.6 

14.4 

16.2 


To  use  this  table,  convert  the  given 
number  of  degrees  Centigrade  into 
degrees  Fahrenheit,  and  add  32°. 


Fahrenheit  to  Centigrade. 

1  =  .555  (4- .000555) 

2  =  1.110 

3  =  1.665 

4  =  2.220 

5  =  2.775 

6  =  3.330 

7  =  3.885 

8  =  4.440 

9  =  4.995 

To  use  this  table  subtract  32°  from 
the  given  number  of  degrees  Fah- 
renheit, and  convert  the  remainder 
into  degrees  Centigrade. 


(/row  Dr.  Craig's  Decimal  System.) 


INDEX. 


Acid  fermentation  of  urine,  23,  106 

Acute  nephritis,  153 

Albumen,  to  detect,  by  heat,  32 

by  nitric  acid,  33 
by  picric  acid,  37 
by  carbolic  acid,  37 
quantitative  estimation  of,  38 

author's  method  of  testing  for  small  quantities  of,  41 
remarks  on  testing  for  small  quantities  of,  40 
Roberts'  quantitative  method  for,  39. 
Albuminoid  degeneration  of  kidney,  156 
Alkaline  fermentation  of  urine,  23,  107 
Alkapton,  46 
Apparatus  required  for  urine  examination,  16 

Bacteria,  149 
Biliary  acids,  76 

Pettenkofer's  test  for,  76 

coloring  matters,  Heller's  test  for,  73 

decomposed,  test  for,  75 
Gmelin's  nitrous  acid  test  for,  72 
Blood,  coloring  matters  of,  in  urine,  65 
Blood-corpuscles  in  the  urine,  139 
recognition  of,  140 

Calculi,  urinary,  159 

to  determine  composition  of,  160 
Carbonate  of  lime,  deposits  of,  127 


168  INDEX. 

Chlorides,  Mohr's  nitrate  of  silver  volumetric  process  for,  95 
clinical  significance  of,  95 
nitrate  of  silver  test  for,  94 
detection  and  approximate  estimation  of,  94 
Coloring  matters,  normal,  57 

abnormal,  65 
vegetable,  71 
Crcatin,  93 
Creatinin,  93 

Cystin,  chemical  characters  of,  129 
deposits,  129 

Deposits,  urinary,  organized,  112 
Dumb-bells  of  oxalate  of  lime,  120 

Entozoa,  151 
Epithelium,  137 

Fungi,  148 

Gonorrhoea,  pus  from,  136 

Haematin,  Heller's  test  for,  68 

test  for  by  precipitation  of  albumen,  etc.,  6D 
Haematinuria,  69 
Haemin  crystals,  to  prepare,  68 
Haemoglobin,  Mahomed's  test  for,  67 

methajmoglobin,  and  haematin,  65 
Hippuric  acid,  93 

Indican  or  indigogen,  61 

Indican,  clinical  significance  of,  in  urine,  64 

Heller's  test  for,  62 

Senator's  method  of  testing  for,  63 
Inorganic  constituents  of  urine,  94 

Kidney,  large  white,  1 54 

fatty  contracting,  155 


INDEX.  169 

Kidney,  acute  inflammation  of,  153 
albuminoid,  156 
chronically  contracted,  155 
parenchymatous  degeneration  of,  157 
true  yellow  fatty,  154 

Leucin  as  a  urinary  deposit,  127 

chemical  characters  of,  128 

detection  of,  78,  127 
Lime,  phosphate  of,  as  a  urinary  sediment,  1 24 

recognition  of,  as  a  urinary  sediment,  126 
Ludwig,  theory  of  secretion  of  urine,  13 

Mahomed's  method  of  testing  for  haemoglobin,  66 
Morbid  growths,  elements  of,  in  urine,  151 
Mucus,  93,  130 
Mucus-casts,  145 
Mucus-corpuscles,  132 

Nephritis,  acute,  153 

chronic  tubal,  154 
interstitial,  153 

Octahedra  of  oxalate  of  lime,  119 

Oxalate  of  lime,  deposits  of,  119 

chemical  characters  of,  120 
clinical  significance  of,  122 
formation  of,  122 
recognition  of,  119 
sources  of,  in  the  urine,  122 

IVnirilium  glaucum,  150 
Phosphate  of  lime,  deposits  of,  1 24 

their  recognition,  1 24 

Phosphates,  alkaline,  approximate  estimation  of,  99 
clinical  significance  of,  100 
nitrate  of  silver  test  for,  99 
15 


170  INDEX. 

Phosphates,  ammonio-magnesian,  deposits  of,  124 

chemical  characters  of,  127 

earthy,  detection  and  approximate  estimation,  97 
as  urinary  sediments,  123 
clinical  significance  of,  98 
of  lime  as  a  urinary  sediment,  1 24 
Phosphoric  acid,  volumetric  process  for,  TOO 
Pigmented  markings  on  glass  slides,  110 
Pus-corpuscle,  132 

action  of  reagents,  133 
Pus,  characters  of  urine  containing,  134 
changes  in  urine  containing,  135 
Donna's  test  for,  134 
sources  of,  in  the  urine,  136 

Reagents  required  for  urine  examination,  15 

Recording  an  examination,  162 

Renal  diseases,  differential  diagnosis  of,  153 

Sarcina,  151 

Selecting  a  specimen  of  urine,  17 
Seminal  tubules,  casts  of,  146 
Specific  gravity  of  urine,  24 

when  increased  or  diminished,  24 
to  determine,  26 

for  very  small  quantities  of  fluid,  26 
Spermatozoids,  148 
Sugar,  fermentation  test  for,  52 

approximate  estimation  by  Moore's  test,  54 

by  Roberts' s  fermentation  test,  54 
volumetric  process  for  estimating,  53 
to  detect  the  presence  of,  by  specific  gravity  and  quantity,  44 
Moore's  and  Heller's  test  for,  44 
Trommer's  test  for,  46 

Fehling's  solution  for  testing  and  estimating,  49,  57 
Pavy's  solution  for  testing  and  estimating,  49,  55 


INDEX.  171 

Sugar,  Piffard's  copper  test  for,  51 

quantitative  estimation  of,  53 

Bcetger's  bismuth  test  for,  51 

Briicke's  modification  of  the  bismuth  test  for,  52 
Sugar  fungus,  150 
Sulphates,  clinical  significance  of,  102 

detection  and  approximate  estimation,  102 
Sulphuric  acid,  volumetric  process  for,  103 

Tables,  1G4 

Tube-casts,  141. 

Tyrosin  as  a  urinary  deposit,  128 

detection  of,  78 

chemical  characters  of,  128 

Urates,  92 

deposits  of,  115 

their  test  and  recognition,  115,  118 
Urea,  volumetric  analysis  for,  by  Liebig's  method,  82 

by  the  hypobromite  process,  87 
detection  and  estimation  of,  79 
Uric  acid,  90 

compounds  of,  115 

their  recognition,  115 
deposits  of,  112 

recognition  of,  112 
tests  for,  114 

detection  by  microscope,  90 
murcxid  test  for,  91 
carbonate  of  silver  test  for,  91 
quantitative  estimation  of,  91 
Urinary  deposits,  105 

classification  of,  111 

rationale  of  production  of  certain  forms,  105 
unorganized,  112 

Urine,  to  prepare  for  examination  for  casts,  14G 
odor  of,  18 


172  INDEX. 

Urine,  organic  constituents  of,  32 

inorganic  constituents  of,  95 

to  determine  solid  matters  of,  29 

order  of  examination  of,  3 1 

coloring  matters  of,  57 

secretion  of,  13 

acid  fermentation  of,  23,  106 

general,  physical,  and  chemical  characters  of,  18 

its  transparency  and  deviations  therefrom,  1 9 

consistence  of,,  and  deviations  therefrom,  21 

color  of,  and  deviations  therefrom,  21 

reaction  of,  22 

selecting  specimens  of,  for  examination,  1 7 

specific  gravity  of,  24 

to  determine  specific  gravity  of,  26 

quantity  of,  and  variations,  27 
Urinometer,  Heller's,  26 
Urochrome  of  Thudicum,  60 
Uroerythrin  in  urine,  70 

detection  of,  70 
clinical  significance  of,  71 

Uroglaucin,  or  indigo  blue,  61  . 

Urohaematin,  Harley's  test  for,  59 

or  urophain   reaction,    clinical   significance   of    in 

creased,  61 

Urophain,  Heller's  test  for,  58 
Uroxanthin,  Heller's  test  for,  62 

Senator's  method  of  testing  for,  63 
Urrhodin,  or  indigo  red,  62 

Vegetable  coloring  matters  in  urine,  71 

detection  of,  71 

Xanthin,  93 
Yeast  fungus,  150 


A  CLASSIFIED  LIST 


WORKS 


MEDICINE,  SURGERY, 


THE  COLLATERAL  SCIENCES, 


PUBLISHED   BY 


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gre 
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440 2  25 


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LEBER  &  ROTTENSTEIN  onDental  Caries.  With  ills.    1  26 
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10  LINDSAY  &  BLAKISTON'S 

SKIN  AND  HAIR. 

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SAVORY'S  Compendium  of  Domestic  Medicine 50 

HUFELAND'S  Art  of  Prolonging  Life.     Edited  by 

Erasmus  Wilson,  M.D.,  F.R.S.T. f.    1  00 

JONES'  Defects  of  Sight  and  Hearing.    Third  Ed....        50 

LEARED  on  Imperfect  Digestion.    Fifth  Edition 1  75 

LIZARS  on  the  Use  and  Abuse  of  Tobacco 50 

MADDEN'S  Principal  Health  Resorts  of  Europe  and 

Africa 2  50 

MILLER  on  Alcohol.    Its  Use  and  Abuse 50 

MILLER  on  Alcohol,  and  LIZAR'S  on  Tobacco.    One 

volume 1  oo 

COTTLE,  The  Hair  in  Health  and  Disease 75 

PARKE'S  Manual  of  Practical  Hygiene.    Fifth  Edi- 
tion.   Illustrations 6  00 

RYAN'S   Philosophy  of  Marriage.     In  its  Social, 

Moral,  and  Physical  Relations.     12mo 1  00 

SMITH'S  Lectures  on  Nursing.     26  engravings 223 

WILSON  on  the  Skin  and  Hair.     Their  Preserva- 
tion, &c.    Eighth  Edition 100 

WILSON'S  Hygiene  and  Sanitary  Science.     Third 

Edition.    Illustrated 3  00 

WALKER  on  Intermarriage.     With  illus'ns.    12mo,    100 

WRIGHT  on  Headaches.    Their  Causes  and  Cure 50 

WILSON'S  Domestic  Hygiene 

THOMPSON  on  Colds  and  Coughs 60 

DOMVILLE'S  Hospital  Nurses 1  00 

WILSON,  Naval  Hygiene.    Illustrations 


PUBLICATIONS.  11 

MISCELLANEOUS. 

ADAMS  on  Club-Foot.     Enlarged  Edition,  illust'd,  6  00 
ADAMS  on  Rheumatic  Gout.  Second  Edition.  With 

a  4to  Atlas  of  Plates.    2  vols 850 

ALLINGHAM  on  the  Rectum.    Second  Edition 200 

AKSTIE  on  Stimulants  and  Narcotics 3  00 

ARNOTT  on  Cancer,  its  Varieties,  Ac.  Illustrations,  226 

BASHAM  on  Dropsy.    Sixteen  plates.    Octavo 500 

BRODHURST  on  Deformities.    New  Edition,  illu.U'd,  600 

CARSON'S  History  University  of  Pennsylvania 2  00 

CLARKE'S  Diseases  of  the  Tongue 5  00 

CLEVELAND'S  PronouneinsiMedical  Lexicon.    19th 

Edition.     Cloth,  1.00;  Tucks 1  25 

COBBOLD  on  Worms 2  00 

CURLING  on  the  Rectum.    Fourth  Edition 275 

DAY  on  Headaches.    2d  Edition 2  00 

DUNGLISON'S  History  of  Medicine 2  50 

DUNGLISON'S  Practitioners'  Reference  Book 3  50 

FLINT  on  Continued  Fevers.    164  Cases.    Octavo...  2  00 

GROSS'S  American  Medical  Biography 3  50 

HOLDEN  on  the  Bphygmognph.    300  illustrations,  2  00 
VIRCIIOW  on  Post-Mortem  Examinations.     16ino...        75 

LIVEING  on  Megrim,  Sick-Headache,  Ac 6  00 

MARSDEN'S  New  Mode  of  Treating  Cancer.    Col- 
ored plates 3  50 

MAYNE'S  Medical  Vocabulary.    Fourth  Edition 3  00 

MENDENHALL'S  Manual  of  Examinations  in  Every 

Branch  of  Medicine,  Surgery,  Ac.    224  ills 2  00 

OVERMAN'S  Practical  Mineralogy,  Assaying,  Ac....  1  00 

PIGGOTT  on  Copper  Mining,  Copper  Ore,  Ac 1 

PRINCE'S  Galvano-Tlierapeutics 1 

PRINCE'S  Plastic  and  Orthopedic  Surgery.    Illust.,  4 

RADCLIFP  on  Epilepsy,  Pain,  Paralysis,  Ac.    Illus..  150 

RIHL  and  O'CONNOR'S  Physician's  Account  Book..  7  oO 

SIEVEKING  on  Life  Assurance " 

STILLE'S  Cerebro-Spinal  Meningitis.    Octavo 200 

SANSOM  on  Chloroform,  its  Action  and  Adminis- 

tration 1  80 

Sydenham's  Society's  Publications.     New  series. 

(See  page  2.)    Per  annum 10 

Sydenham  Reports  on  the  Progress  of  Medicine,  Ac.,  2  00 

The  Pennsylvania  Hospital  Reports.    2  vols.,  each  200 
The  Physician's  Visiting  List.    Various  sizes  and 

prices.    (See  page  2.) 
TBANSACTIONS  College  of  Physicians.    New  series. 

Vola.l,  2.  and  3-    Each  volume 2  W> 

TURNBULL  on  Anaesthesia.  Paper,  .75  ;  cloth 1 

WILKES'  Nervous  Diseases 5  00 


IMPORTANT  NEW  ILLUSTRATED  WORKS. 

BBAUNE'S  Atlasof  Topographical  Anatomy.  After 
Plane  Sections  of  Frozen  Bodies,  containing 
34  full-page  photographic  plates  and  numerous 
other  illustrations  on  wood.  Translated  and  ed- 
ited by  Edward  Bellamy,  F.R.C.S.,  Lecturer  on 
Anatomy  and  Teacher  of  Operative  Surgery, 
Charing  Cross  Hospital.  A  large  quarto  volume. 
Cloth,  12.00;  Half  Morocco, 1400 

SAVAGE'S  Surgery,  Surgical  Pathology,  and  Surgi- 
cal Anatomy  of  the  Female  Pelvic  Organs,  in  a 
series  of  colored  plates,  taken  from  nature,  with 
commentaries,  notes,  and  cases.  Third  Edition, 
greatly  enlarged.  A  quarto  volume 14  00 

Fox's  Atlas  of  Skin  Diseases.  Complete  in  18 
parts,  each  containing  four  chromo-lithographic 
plates  and  numerous  figures,  with  descriptive 
text  and  notes  upon  treatment.  Royal  4to.  Price 
of  each  part,  2.00;  bound  in  Cloth 30  00 

HEATH'S  Operative  Surgery.  With  plates  drawn 
from  nature,  and  colored  by  hand.  Each  part  con- 
taining four  plates,  and  numerous  figures.  Im- 
perial Quarto.  Complete  in  five  parts,  each  2.50; 
In  Cloth ." 14  00 

HUTCHINSON'S  Illustrations  of  Clinical  Surgery. 
Consisting  of  plates,  photographs,  wood-cuts,  dia- 
grams, &c.,  illustrating  surgical  diseases,  symp- 
toms, and  accidents  ;  also,  operations  and  other 
methods  of  treatment.  With  descriptive  letter- 
press, &c.  In  quarterly  fasciculi.  Imperial  4to. 
Ten  fasciculi  now  ready.  Each 2  50 

BENTLEY  &  TRIMEN'S  Medicinal  Plants.  Being  de- 
scriptions, with  original  figures,  of  the  principal 
plants  employed  in  medicine,  and  an  account  of 
their  properties  and  uses.  To  be  completed  in 
about  Forty  monthly  parts.  With  colored  illus- 
trations, natural  size.  Large  8vo.  Thirty-four 
parts  now  ready.  Each 2  00 

GODLEE'S  Anatomical  Atlas.  To  be  completed  in  12 
or  13  folio  parts,  with  references,  Ac.  4  plates  in 
each.  Four  ready.  Price  per  part 2  50 

Subscriptions  received  by  Ike  Publishers  to  be  delivered  or 
sent  free  by  mail  or  express,  full  Prospectuses  furnished  on 
application.  GOOD  CANVASSING  AGENTS  are  wanted 
for  these  and  other  important  Medical  Works  now  in  course  of 
publication 

'LINDSAY  &  BLAKISTON,  Publishers, 

PHILADELPHIA. 


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